§ 1163.59. Noncompensable services, items and outlier days.
(a) The Department does not pay hospitals for an inpatient hospital stay if the admission is directly or indirectly related to the hospital’s provision of:
(1) Transsexual surgical procedures for gender change or reassignment—for example, penile construction, revision of labia, vaginoplasty, vaginal dilation, vaginal reconstruction, penectomy, orchiectomy, mammoplasty, mastectomy, hysterectomy and release of vaginal adhesions.
(2) Medical or dental services or surgical procedures performed on an inpatient basis which could have been performed in an outpatient department, or practitioner’s office—for example, unilateral or bilateral myringotomy, vasectomy, blood transfusions, chronic maintenance hemodialysis, treatment for chronic pain and dental procedures which may be provided in an outpatient setting without undue risk to the patient.
(3) Inpatient hospital services provided in conjunction with physicians’ services which are identified as outpatient procedures in Chapter 1150 (relating to the MA Program payment policies), unless performing the procedure on an outpatient basis could result in undue risk to the life or health of the patient and detailed documentation of the conditions of risk to the life or health of the patient is included in the patient’s medical record.
(4) Acupuncture, unnecessary surgery, insertion of penile prosthesis, gastroplasty for morbid obesity, gastric stapling or ileojejunal shunt, except when all other types of treatment of morbid obesity have failed and other procedures which may be experimental are not in accordance with customary standards of medical practice or are not commonly used.
(5) 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, reduction mammoplasty, augmentation mammoplasty, silicone or silastic implants, facioplasty, osteoplasty—prognathism and micrognathism—dermabrasion, skin grafts and lipectomy. For accidental injury, plastic surgery is compensable if performed for the purpose of improving the functioning of a deformed body member.
(6) Inpatient dental cases 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 performing the procedure in the dentist’s office or other outpatient setting.
(ii) A physician or dentist has documented in the patient’s medical record the medical justification for performing the procedure in a short procedure unit or inpatient setting.
(7) Diagnostic tests and procedures that can be performed on an outpatient basis and diagnostic tests and procedures not related to the diagnoses that require that particular inpatient stay.
(8) Sterilizations performed on individuals 20 years of age or younger.
(9) Sterilizations 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.
(10) Hysterectomies performed solely for the purpose of sterilization.
(11) Abortion procedures performed on individuals if a ‘‘Physician Certification for an Abortion’’ form has not been completed.
(12) Services and items for which full payment is available through Medicare, other financial resources or other health insurance programs.
(13) Services and items not ordinarily provided to the general public.
(14) Methadone maintenance.
(15) Diagnostic or therapeutic procedures solely for experimental, research or educational purposes.
(16) Unnecessary admissions and conditions which do not require hospital-type care, such as rest cures and room and board for relatives during a patient’s hospitalization.
(b) The Department does not pay for an inpatient hospital stay if the admission is not certified under the Department’s DRG review process.
(c) For purposes of determining a day outlier under § 1163.56 (relating to outliers) the following days are excluded:
(1) Days of absence from the hospital.
(2) Inpatient days for patients who no longer require acute short term inpatient hospital care—inappropriate hospital services. For patients who require skilled nursing or intermediate care, payment is made to the hospital for this care under Chapter 1181 (relating to nursing facility care) only if the patient is in a certified and approved hospital-based skilled nursing or intermediate care unit.
(3) Days of inpatient care due to unnecessary delays in applying for a court ordered commitment, grace periods, administrative days and custodial care related or unrelated to court commitments or to protective services. For purposes of this chapter, custodial care is defined as maintenance, rather than curative care, on an indefinite basis, while grace periods and administrative days relate to days of care while awaiting placement elsewhere.
(4) Days spent as an inpatient at the transferring hospital on or after the effective date of a court commitment to another facility.
(5) Inpatient days caused by the hospital’s failure to promptly request or perform necessary diagnostic studies, medical-surgical procedures or consultations.
(6) Inpatient days when the patient is admitted on a Friday or Saturday and no medical or surgical procedure is performed on the day of or the day following admission, unless the admission is an emergency as documented in the patient’s medical record by the attending physician.
(7) Inpatient days resulting from the provision of a noncompensable service or item specified in subsection (a).
(8) Inpatient days resulting from a patient’s refusal to leave the hospital after being discharged by the attending physician.
(9) The day of discharge from inpatient hospital care.
(d) The Department will not make payment for drug or alcohol detoxification services in an inpatient hospital unless one of the following circumstances exist:
(1) Complications exist, or there is a reasonable expectation of complications, that require inpatient hospital medical treatment, including:
(i) The presence or reasonable expectation, based on history or other demonstrable findings, of potentially dangerous withdrawal symptoms which could endanger the health or safety of the individual.
(ii) The presence or reasonable expectation, based on history or other demonstrable findings, of major medical complications.
(iii) The presence of a significant psychiatric problem on admission.
(iv) The presence of a clinical state requiring close medical observation.
(2) A nonhospital, medically appropriate bed is not available within a 50-mile radius of the inpatient hospital to which the patient presents for treatment and the inpatient hospital includes documentation of the nonavailability of the nonhospital detoxification bed in the medical record. A nonhospital detoxification bed will be considered to be not available if the medically appropriate nonhospital facility has no beds available or refuses to accept the patient.
Authority The provisions of this § 1163.59 amended under sections 201(2) and 443.1(1) and (4) of the Public Welfare Code (62 P. S. § § 201(2) and 443.1(1) and (4)).
Source The provisions of this § 1163.59 adopted September 23, 1983, effective September 24, 1983, 13 Pa.B. 2881; amended June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended February 28, 1986, effective March 1, 1986, 16 Pa.B. 600; amended November 7, 1986, effective July 1, 1986, 16 Pa.B. 4384; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended August 18, 1989, effective immediately, retroactively applicable to August 1, 1988; amended June 1, 1990, effective retroactively to July 1, 1988, 20 Pa.B. 2913; corrected August 3, 1990, effective July 1, 1988, 20 Pa.B. 4199; amended November 3, 1995, effective November 4, 1995, and apply retroactively to October 1, 1995, 25 Pa. B. 4700; amended November 24, 1995, effective November 25, 1995, apply retroactively to November 1, 1995, 25 Pa. B. 5241. Immediately preceding text appears at serial pages (201299) to (201302).
Notes of Decisions Although DPW’s delay in approving transfer to rehab center resulted in hospital continuing to care for patient who no longer needed acute inpatient care, Office of Hearings and Appeals’ decision denying reimbursement was affirmed. The regulations do not allow for discretion in their application. [Note citation to § 9421.74, 7 Pa.B. 2179, 2180 (1977)] Mercy Hospital v. Department of Public Welfare, 492 A.2d 104 (Pa. Cmwlth. 1985).
Cross References This section cited in 55 Pa. Code § 1150.59 (relating to PSR Program); and 55 Pa. Code § 1163.78b (relating to review requirements for cost outliers).
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