1. (1) This section contains general information on coverage and limitations for physician services.

   1. (a) Physician services may be provided only within the parameters of accepted medical practice and are subject to limitations and exclusions established by the department based on appropriateness, medical necessity, and utilization control considerations.
   2. (b) Medicaid covers cosmetic or reconstructive procedures pursuant to Section R414-1-29.
   3. (c) Medicaid covers experimental or medically unproven physician services pursuant to Rule R414-1A.

   4. (d) Program limitations and non-covered services are maintained in the Coverage and Reimbursement Code Lookup and updated by notification through the Medicaid Information Bulletin. Medicaid may not cover any:

      1. (i) medically unnecessary or unreasonable service;
      2. (ii) paternity test;
      3. (iii) service claimed fraudulently;
      4. (iv) service, elective in nature, based on patient request or individual preference rather than medical necessity;
      5. (v) service provided during a period in which an individual is ineligible for Medicaid;
      6. (vi) service provided without required prior authorization;
      7. (vii) service rejected or disallowed by Medicare when the rejection is based on any reason listed in this section;
      8. (viii) service that fails to meet existing standards of professional practice;
      9. (ix) service that represents abuse or overuse;
      10. (x) related service, supply, or institutional cost during a post-operative recovery period, if the service or procedure is not covered for any reason specified in this section or due to policy exclusion; and

      11. (xi)(A) service for which third party payers are primarily responsible for coverage, such as Medicare, private health insurance, and liability insurance, pursuant to Rule R527-936.

          1. (B) Medicaid may make a partial payment up to the Medicaid maximum if a third party does not reach the payment limit.
   5. (e) Medicaid covers treatment for alcoholism or drug dependency in an inpatient setting pursuant to Subsection R414-2A-7(1).

2. (2) Medicaid may not cover the following family planning services:

   1. (a) any surgical procedure for the reversal of previous elective sterilization on both males and females; or
   2. (b) surrogate motherhood, including any service, test, and related charge.
3. (3) Medicaid may only cover anesthesia services performed by a licensed, qualified provider.
4. (4) Medicaid may not cover any anesthesia standby service.

5. (5) Medicaid may cover the following surgical global services and procedures:

   1. (a) preoperative examination, initiation of the hospital record, and development of a treatment program either in the physician's office on the day before admission, in the hospital, or in the physician's office on the same day as hospital admission;
   2. (b) the operation;
   3. (c) any topical, local, or regional anesthesia; and
   4. (d) the normal, uncomplicated follow-up care covering the period of hospitalization and office follow-up for progress checks or any service directly related to the surgical procedure.

6. (6) The following criteria apply to global services.

   1. (a) A physician may not bill for an office visit the day before surgery, for preadmission or admission workup, or for subsequent hospital care while the patient is being prepared, hospitalized, or under care for a global surgical service.

   2. (b)(i) Only the consulting physician may bill for consultation services when consultation and no other service is provided.

      1. (ii) When a consulting physician admits and follows a patient, independently or concurrently with the primary physician, the consulting physician may only use admission codes and subsequent care codes.

   3. (c)(i) Office visits after hospitalization that relate to the same diagnosis are part of the global service.

      1. (ii) The only exception to either inpatient or office service is for a service related to a complication, exacerbation, or recurrence of another disease or problem requiring an additional or separate service.
   4. (d) Any complication, exacerbation, recurrence, or the presence of another disease or injury, which requires a service concurrent with the initial surgical procedure during the listed period of normal follow-up care, may warrant additional charges only when the record shows extensive documentation and justification of the additional service.
   5. (e) When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods continue concurrently to the follow-up periods' normal terminations.

   6. (f) Preoperative examination and planning are covered as separate services only under the following circumstances:

      1. (i) when the preoperative visit is the initial visit for the physician and prolonged detention or evaluation is required to establish a diagnosis to determine the need for a specific surgical procedure or to prepare the patient;
      2. (ii) when the preoperative visit is a consultation and the consulting physician does not assume care of the patient; or
      3. (iii) when diagnostic procedures are not part of the basic surgical procedure.
7. (7) Medicaid may not cover early elective delivery, whether vaginal or caesarean, before 39 weeks.
8. (8) Limited abortion services shall meet the requirements of Rule R414-1B.
9. (9) Sterilization and hysterectomy procedures shall meet the requirements of 42 CFR 441 Subpart F (2024).
10. (10) Organ transplant services shall meet the requirements of Rule R414-10A.

11. (11) Medicaid may cover the following psychiatric services as a medical benefit:

    1. (a) a mental health service that targets the diagnosis or treatment of developmental disability or organic disorder;
    2. (b) a physician-ordered psychiatric service for a patient hospitalized in a non-psychiatric unit of a hospital; or
    3. (c) a psychosocial evaluation requested before organ transplant, a psychiatric evaluation before another medical service or surgical procedure, and an evaluation for an individual with a condition that requires chronic pain management services.

12. (12) Medicaid may cover the following pain management services:

    1. (a) pain management for delivery and acute post-operative pain; and
    2. (b) treatment for chronic pain.
13. (13) Medicaid may cover a prescription medication subject to the requirements of Rule R414-60.

KEY: Medicaid

Date of Last Change: November 13, 2025

Notice of Continuation: October 19, 2021

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108; 26B-3-215; 26B-3-216