PURPOSE: This rule establishes the basis, procedure and criteria where the state Medicaid agency may grant an exception to benefit limitations otherwise imposed by the state’s Medicaid program.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

1. (1) Under the requirements of this rule, the Division of Medical Services (DMS) may approve and authorize payment for the provision to a Medicaid-eligible recipient of an essential medical service or item that would otherwise exceed the benefit limitations of the medical assistance program. An administrative exception may be made on a case-by-case basis to limitations and restrictions. No exception can be made where requested items or services are restricted or specifically prohibited by state or federal law, or excluded under the provisions of section (3) of this rule. The director of the DMS will have the final authority to approve payment on a request made to the exception process. These decisions will be made with appropriate medical or pharmaceutical advice and consultation.

2. (2) Requirements for consideration and provision of a service as an exception to the normal limitations of Medicaid coverage are as follows:

   1. (A) A physician, resident, intern, extern, nurse clinician, nurse practitioner or registered nurse (RN) acting on the behalf of the physician must certify that medical treatment or items of service which are covered under the Medicaid Program and which, under accepted standards of medical practice, are 13 CSR 70-2

indicated as appropriate to the treatment of the illness or condition, have been used and found to be medically ineffective in the treatment of the recipient for whom the exception is being requested or inappropriate for that specific recipient;

1. (B) All third-party resource benefits must be exhausted before the Medicaid program will pay for any treatment or service;
2. (C) Any drug requested has been approved by the Food and Drug Administration (FDA) and is being prescribed for an FDA-approved indication and route of administration or medical literature must exist justifying the effectiveness of the drug or that specific diagnosis or for that specific route of administration;
3. (D) Any medical, surgical or diagnostic service requested which is provided by a physician must be listed in the most recent publication of the Physicians’ Current Procedural Terminology, Fourth Edition (CPT-4);
4. (E) Any individual for whom an exception request is made must be eligible for Medicaid on the date(s) the item or services are provided or in the case of retroactive eligibility approval can be granted if requested;
5. (F) The provider of the service must be an enrolled provider in the Medicaid program on the date(s) the item or services are provided;
6. (G) The item or services for which an exception is requested must be of a type and nature which falls within the broad scope of a medical discipline included in the Medicaid program and which does not represent a departure from the accepted standards and precepts of good medical practice;
7. (H) Requests must be made and approval granted before the requested item or services are provided, or not more than one (1) state working day following the provision of the service. Retroactive approval of coverage may be granted in cases in which the recipient’s eligibility for Medicaid is established;
8. (I) All requests for exception consideration must be initiated by the attending physician the resident, intern, extern, nurse clinician, nurse practitioner or RN acting in the physician’s behalf for an eligible recipient and must be submitted as prescribed in policy of the DMS;

9. (J) Requests for exception consideration, by whatever means received, must support and demonstrate that one (1) or more of the following conditions are met:

   1. 1. The item or service is required to sus-

tain the recipient’s life;

1. 2. The item or service would substantially

improve the quality of life for a terminally ill patient;

1. 3. The item or service is necessary as a

replacement due to an act occasioned by violence of nature without human interference, such as a tornado or flood; or

1. 4. The item or service is necessary to

prevent a higher level of care;

1. (K) All exception requests must represent cost-effective utilization of Medicaid funds. When an exception item or service is presented as an alternative, lesser level-of-care than the level otherwise necessary, the exception must be less program costly; and
2. (L) Reimbursement of services and items approved under this exception procedure shall be made in accordance with the Medicaidestablished fee schedules or rates for the same or comparable services. For those services for which no Medicaid-established fee schedule or rate is applicable, reimbursement will be determined by the state agency considering costs and charges.

1. (3) Consideration under this rule shall not be applicable to requests for services under the following circumstances such as, but not limited to:

   1. (A) Requests for General Relief recipients for noncovered services or program areas;
   2. (B) Services that would be provided by individuals whose specialty is not covered by the Medicaid program, such as chiropractic services;
   3. (C) Orthodontics;
   4. (D) Inpatient hospital services;
   5. (E) Air transportation;
   6. (F) Alternative services such as personal care, adult day health care, homemaker/ chore, hospice and respite care, regardless of authorization by the Division of Aging;
   7. (G) Psychological testing or counseling provided by professionals other than psychiatrists;
   8. (H) Waiver of Medicaid program requirements for documentation, applicable to services requiring a second surgical opinion, voluntary sterilization, hysterectomies or legal abortions;
   9. (I) Failure to obtain prior authorization as required for a service otherwise covered by Medicaid;
   10. (J) Delivery or placement of custom-made items following the recipient’s death or loss of eligibility for the service;
   11. (K) Previous denial by the Medicaid state agency of a request for exception consideration where the current request fails to present information of significance in overcoming the deficiency upon which the original request was denied;
   12. (L) Requests for additional reimbursement for items or services otherwise covered by the Medicaid program;
   13. (M) Over-the-counter drugs;
   14. (N) Providing additional covered drugs when recipient has used his/her five (5) prescriptions per month;
   15. (O) Qualified Medical Benefits services (QMB);
   16. (P) Medicaid waiver services such as Children’s Waiver, Acquired Immunodeficiency Syndrome (AIDS) Waiver, Community Psychiatric Rehabilitation Waiver or Mentally Retarded Developmental Disabled Waiver; and
   17. (Q) Transplants.

AUTHORITY: sections 207.020, 208.153 and 208.201, RSMo Supp. 1989.* This rule was previously filed as 13 CSR 40-81.195. Original rule filed May 15, 1987, effective Oct. 11, 1987. Amended: Filed June 4, 1990, effective Dec. 31, 1990.

*Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; and 208.201, RSMo 1987.