§ 1126.54. Noncompensable services and items.
(a) The Department does not pay ASCs and SPUs for services directly or indirectly related to, or in conjunction with:
(1) A service not designated by the Department as appropriate to be performed in an ASC or SPU.
(2) A service that does not conform to the requirements of this chapter.
(3) A sterilization performed on individuals 20 years of age or younger.
(4) A sterilization performed on individuals 21 years of age or older who have not signed the Consent Form for Sterilization at least 30 days but not more than 180 days prior to the sterilization.
(5) Abortion procedures performed on individuals if a Physician Certification for an Abortion form has not been completed.
(6) A service provided by an ambulatory surgical center that does not meet the Federal Medicare requirements at 42 CFR 416 (relating to ambulatory surgical services).
(7) Procedures and medical care performed in connection with sex reassignment.
(8) Medical, dental or surgical procedures which may be provided in a clinic or practitioner’s office without undue risk to the patient.
(9) Plastic or cosmetic surgery for beautification purposes—for example, otoplasty for protruding ears or lop ears, rhinoplasty—except for internal nasal deformity—nasal reconstruction, excision of keloids, mammoplasty, silicone or silastic implants, dermabrasion, skin grafts and lipectomy. Plastic surgery is compensable if performed for the purpose of improving the functioning of a deformed body member.
(10) A dental case involving oral rehabilitation or restorative services, except for procedures performed for treatment of a secondary diagnosis, unless:
(i) The nature of the surgery or the condition of the patient precludes the procedure in the dentist’s office.
(ii) A physician or dentist has documented in the patient’s medical record the medical justification for performing the procedure in an ASC/SPU setting.
(11) Diagnostic tests and procedures that can be performed in a clinic or practitioner’s office and diagnostic tests and procedures not related to the diagnosis.
(12) Services and items for which full payment equal to or in excess of the Medical Assistance fee, is available through Medicare, other financial resources or other health insurance programs.
(13) Services and items not ordinarily provided to the general public.
(14) A diagnostic or therapeutic procedure solely for experimental, research or educational purposes.
(15) A procedure that is not listed under the Medical Assistance Fee Schedule.
(16) A service that is not medically necessary.
(b) The Department will not pay for same day surgical services if the admission to the ASC or SPU is not certified under the Department’s utilization review process applicable to the type of provider furnishing the service.
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