HEALTH CARE AUTHORITY

[Filed January 10, 2024, 10:13 a.m., effective February 10, 2024]

Effective Date of Rule: Thirty-one days after filing.

Purpose: The agency is revising these rules to include coverage for adult cochlear implants for apple health (medicaid) clients, update cochlear implant device coverage criteria, and revise the expedited prior authorization explanation. This permanent rule adoption supersedes the emergency rules filed under WSR 24-02-047 on December 28, 2023.

Citation of Rules Affected by this Order: Amending WAC 182-531-0200 and 182-531-0375.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Adopted under notice filed as WSR 23-24-002 on November 27, 2023.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

Date Adopted: January 10, 2024.

AMENDATORY SECTION(Amending WSR 15-16-084, filed 7/31/15, effective 8/31/15)

WAC 182-531-0200Physician-related and health care professional services requiring prior authorization.

(1) The medicaid agency requires prior authorization for certain services. Prior authorization includes expedited prior authorization (EPA) and limitation extension (LE). See WAC 182-501-0165.

(2) ((The)) EPA ((process)) is designed to eliminate the need for ((telephone prior))written authorization ((for selected admissions and procedures)). The agency establishes authorization criteria and identifies the criteria with specific codes, enabling providers to use that EPA number if a client meets the EPA criteria.

(a) The provider must create an authorization number using the process explained in the medicaid agency's physician-related billing instructions.

(b) Upon request, the provider must provide supporting clinical documentation to the medicaid agency showing how the authorization number was created.

(c) Selected nonemergency admissions to contract hospitals require EPA. These are identified in the medicaid agency billing instructions.

(d) Procedures allowing expedited prior authorization include, but are not limited to, the following:

(i) Reduction mammoplasties/mastectomy for gynecomastia;

(ii) Strabismus surgery for clients ((eighteen))18 years of age and older;

(iii) Meningococcal vaccine;

(iv) Placement of drug eluting stent and device;

(v) Cochlear implant((s for clients twenty years of age and younger))devices;

(vi) Hyperbaric oxygen therapy;

(vii) Visual exam/refraction for clients ((twenty-one))21 years of age and older;

(viii) Blepharoplasties; and

(ix) Neuropsychological testing for clients ((sixteen))16 years of age and older.

(3) The medicaid agency evaluates new technologies under the procedures in WAC 182-531-0550. These require prior authorization.

(4) Prior authorization is required for the following:

(a) Abdominoplasty;

(b) All inpatient hospital stays for acute physical medicine and rehabilitation (PM&R);

(d) Diagnosis and treatment of eating disorders for clients ((twenty-one))21 years of age and older;

(e) Osteopathic manipulative therapy in excess of the medicaid agency's published limits;

(f) Panniculectomy;

(g) Bariatric surgery (see WAC 182-531-1600);

(h) Vagus nerve stimulator insertion, which also:

(i) For coverage, must be performed in an inpatient or outpatient hospital facility; and

(ii) For reimbursement, must have the invoice attached to the claim.

(i) Osseointegrated/bone anchored hearing aids (BAHA) for clients ((twenty))20 years of age and younger;

(j) Removal or repair of previously implanted BAHA or cochlear implant devices for clients ((twenty one))21 years of age and older when medically necessary; and

(k) Gender reassignment surgery (see WAC 182-531-1675).

(5) All hysterectomies performed for medical reasons may require prior authorization, as explained in subsection (2) of this section.

(a) Hysterectomies may be performed without prior authorization in either of the following circumstances:

(i) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or

(ii) A hysterectomy is needed due to trauma.

(b) The agency reimburses all attending providers for a hysterectomy procedure only when the provider submits an accurately completed agency-approved consent form with the claim for reimbursement.

(6) The medicaid agency may require a second opinion and/or consultation before authorizing any elective surgical procedure.

(7) Children six years of age and younger do not require authorization for hospitalization.

AMENDATORY SECTION(Amending WSR 15-03-042, filed 1/12/15, effective 2/12/15)

WAC 182-531-0375Audiology services.

(1) The agency covers((,))medically necessary cochlear implant devices with prior authorization((, cochlear devices for clients twenty years of age and younger with the following limitations:

(a) The client meets one of the following:

(i) Has a diagnosis of profound to severe bilateral, sensorineural hearing loss;

(ii) Has stimulable auditory nerves but has limited benefit from appropriately fitted hearing aids (e.g., fail to meet age-appropriate auditory milestones in the best-aided condition for young children, or score of less than ten or equal to forty percent correct in the best-aided condition on recorded open-set sentence recognition tests);

(iii) Has the cognitive ability to use auditory clues;

(iv) Is willing to undergo an extensive rehabilitation program;

(v) Has an accessible cochlear lumen that is structurally suitable for cochlear implantation;

(vi) Does not have lesions in the auditory nerve and/or acoustic areas of the central nervous system; or

(vii) Has no other contraindications to surgery; and

(b) The procedure is performed in an inpatient hospital setting or outpatient hospital setting))for eligible clients.

(2) The agency covers BAHAs for clients ((twenty))20 years of age and younger with prior authorization.

(3) The agency covers replacement parts and batteries for BAHAs and cochlear implant devices ((for clients twenty years of age and younger only)). See WAC 182-547-0800 and 182-547-0850.

(4) The agency considers requests for removal or repair of previously implanted BAHAs and cochlear implant devices ((for clients twenty one years of age and older only)) when medically necessary. Prior authorization from the agency is required.

(((5) For audiology, the agency limits:

(a) Caloric vestibular testing to four units for each ear; and

(b) Sinusoidal vertical axis rotational testing to three units for each direction.))