Section 140.413  Limitation on Physician Services

 

a)         When provided in accordance with the specified limitations and requirements, the Department shall pay for the following services:

 

1)         Termination of pregnancy – only in those cases in which the physician has certified in writing to the Department that the procedure is necessary to preserve the life of the mother.  All claims for reimbursement for abortions or induced miscarriages or premature births must be accompanied by the physician's written certification that the procedure is necessary for preservation of the life of the woman, or that the induced premature birth was to produce a live viable child and was necessary for the health of the mother or her unborn child.

 

2)         Sterilization

 

A)        Therapeutic sterilization – only when the procedure is either a necessary part of the treatment of an existing illness, or is medically indicated as an accompaniment of an operation on the female genitourinary tract.  Mental incapacity does not constitute an illness or injury that would authorize this procedure.

 

B)        Nontherapeutic sterilization – only for recipients age 21 or older and mentally competent. The physician must obtain the recipient's informed written consent in a language understandable to the recipient before performing the sterilization and must advise the recipient of the right to withdraw consent at any time prior to the operation.  The operation shall be performed no sooner than 30 days and no later than 180 days following the date of the recipient's written informed consent, except in cases of premature delivery or emergency abdominal surgery.  An individual may consent to be sterilized at the time of premature delivery or emergency abdominal surgery if at least 72 hours have passed since informed consent was given.

 

3)         Surgery for morbid obesity – the Department shall approve payment for this service only in those cases in which the physician determines that obesity is exogenous in nature, the recipient has had the benefit of other therapy with no success, endocrine disorders have been ruled out, and the body mass index (BMI) is 40 or higher, or 35 to 39.9 with serious medical complications.  The medical record must contain the following documentation of medical necessity:

 

A)        Documentation of review of systems (history and physical);

 

B)        Client height, weight and BMI;

 

C)        Listing of co-morbidities;

 

D)        Patient weight loss attempts;

 

E)         Current and complete psychiatric evaluation indicating the patient is an appropriate candidate for weight loss surgery; and

 

F)         Documentation of nutritional counseling.

 

4)         Psychiatric services

 

A)        Treatment – when the services are provided by a physician who has been enrolled as an approved provider with the Department.  Psychiatric treatment services are not covered services for recipients of General Assistance.

 

B)        Consultation – only when necessary to determine the need for psychiatric care.  Services provided subsequent to the initial consultation must comply with the requirements for treatment.

 

C)        Group Psychotherapy – payment may be made for up to two group sessions per week, with a maximum of one session per day.  The following conditions must be met for group psychotherapy:

 

i)          documentation maintained in the patient's medical record must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases (ICD-9-CM) or the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).  The allowable diagnosis code ranges will be specified in the Handbook for Physicians; and

 

ii)         beginning 1/1/10, the entire group psychotherapy service is directly performed by a physician licensed to practice medicine in all its branches who has completed an approved general psychiatry residency program or is providing the service as a resident or attending physician at an approved or accredited residency program; and

 

iii)         the group size does not exceed 12 patients, regardless of payment source; and

 

iv)        the minimum duration of a group session is 45 minutes; and

 

v)         the group session is documented in the patient's medical record by the rendering physician, including the session's primary focus, level of patient participation, and begin and end times of each session; and

 

vi)        the group treatment model, methods, and subject content have been selected on evidence-based criteria for the target population of the group and follows recognized practice guidelines for psychiatric services; and

 

vii)        the group session is provided in accordance with a clear written description of goals, methods and referral criteria; and

 

viii)       if the patient is a resident of a long term care facility, the provider of the group psychotherapy must maintain documentation in the patient's medical record demonstrating the coordination of services and the sharing with the long term care facility of information related to the patient's needs and the implementation and effectiveness of the patient's plan of care.

 

5)         Services provided to a recipient in his or her home – only when the recipient is physically unable to go to the physician's office.

 

6)         Services provided to recipients in group care facilities by a physician other than the attending physician – only for emergency services provided when the attending physician of record is not available or when the attending physician has made referral with the recipient's knowledge and permission.

 

7)         Services provided to recipients in a group care facility by a physician who derives a direct or indirect profit from total or partial ownership (or from other types of financial investment for profit in the facility) – only when occasioned by an emergency due to acute illness or unavailability of essential treatment facilities in the vicinity for short-term care pending transfer, or when there is no comparable facility in the area.

 

8)         Maternity care – Payment shall be made for pre-natal and post-natal care only when the following conditions are met:

 

A)        the physician, whether based in a hospital, clinic or individual practice, retains hospital delivery privileges, maintains a written referral arrangement with another physician who retains such privileges, or has been included in the Maternal and Child Health Program as a result of having entered into an appropriate Healthy Moms/Healthy Kids Program provider agreement;

 

B)        the written referral agreement is kept on file and is available for inspection at the physician's place of business, and details procedures for timely transfer of medical records; and

 

C)        maternal services are delivered in a manner consistent with the quality of care guidelines published by the American College of Obstetricians and Gynecologists in the current edition of the "Standards for Obstetric-Gynecologic Services" (1989 Edition), 409 12^th Street, S.W., Washington, D.C. 20024-2188.

 

9)         Physician services to children under age 21

 

A)        Payment shall be made only when the physician meets one or more of the following conditions.  The physician:

 

i)          has admitting privileges at a hospital; or

 

ii)         is certified or is eligible for certification in pediatrics or family practice by the medical specialty board recognized by the American Board of Medical Specialties; or

 

iii)         is employed by or affiliated with a Federally Qualified Health Center; or

 

iv)        is a member of the National Health Service Corps; or

 

v)         has been certified by the Secretary of the Department of Health and Human Services as qualified to provide physician services to a child under 21 years of age; or

 

vi)        has current, formal consultation and referral arrangements with a pediatrician or family practitioner for the purposes of specialized treatment and admission to a hospital.  The written referral agreement is kept on file and is available for inspection at the physician's place of business, and details procedures for timely transfer of medical records; or

 

vii)        has entered into a Maternal and Child Health provider agreement or has otherwise been transferred in from the Healthy Moms/Healthy Kids Program;

 

B)        The physician shall certify to the Department the way in which he or she meets the above criteria; and

 

C)        Services to children shall be delivered in a manner consistent with the standards of the American Academy of Pediatrics and rules published by the Illinois Department of Public Health (77 Ill. Adm. Code 630, Maternal and Child Health Services; 77 Ill. Adm. Code 665, Child Health Examination Code; 77 Ill. Adm. Code 675, Hearing Screening; 77 Ill. Adm. Code 685, Vision Screening).

 

10)        Hysterectomy – only if the individual has been informed, orally and in writing, that the hysterectomy will render her permanently incapable of reproducing and the individual has signed a written acknowledgment of receipt of the information.  The Department will not pay for a hysterectomy that would not have been performed except for the purpose of rendering an individual permanently incapable of reproducing.

 

11)        Selected surgical procedures, including:

 

A)        Tonsillectomies or Adenoidectomies

 

B)        Hemorrhoidectomies

 

C)        Cholecystectomies

 

D)        Disc Surgery/Spinal Fusion

 

            E)         Joint Cartilage Surgery/Meniscectomies

 

F)         Excision of Varicose Veins

 

G)        Submucous Resection/Rhinoplasty/Repair of Nasal System

 

H)        Mastectomies for Non-Malignancies

 

I)          Surgical procedures that generally may be performed in an outpatient setting (see Section 140.117) only if the Department authorizes payment. The Department will in some instances require that a second physician agree that the surgical procedure is medically necessary prior to approving payment for one of these procedures.  The Department will require a second opinion when the attending physician has been notified by the Department that he or she will be required to obtain prior approval for payment for the surgeries listed.  (See Sections 140.40 through 140.42 for prior approval requirements.)  The Department will select physicians for this requirement based on the recommendation of a peer review committee that has reviewed the utilization pattern of the physician.

 

12)       Mammography screening

 

A)        Covered only when ordered by a physician for screening by low-dose mammography for the presence of occult breast cancer under the following guidelines:

 

i)          a baseline mammogram for women 35 through 39 years of age; and

 

ii)         a mammogram once per year for women 40 years of age or older.

 

B)        As used in this subsection (a)(12), "low-dose mammography" means the x-ray examination of the breast using equipment specifically designated for mammography that will meet appropriate radiological standards.

 

13)       Pap tests and prostate-specific antigen tests – coverage is provided for the following:

 

A)        An annual cervical smear or Pap smear test for women.

 

B)        An annual digital rectal examination and a prostate-specific antigen test, upon the recommendation of a physician licensed to practice medicine in all its branches, for:

 

i)          asymptomatic men age 50 and over;

 

ii)         African-American men age 40 and over; and

 

iii)         men age 40 and over with a family history of prostate cancer.

 

b)         In cases in which a physical examination by a second physician is needed, the Department will notify the recipient and designate a physician to perform the examination.  Physicians will be subject to this requirement for six months, after which a request can be submitted to the peer review committee to consider removal of the prior approval requirement.

 

(Source:  Amended at 33 Ill. Reg. 12227, effective October 1, 2009)