PDFWAC 182-531-0150

Noncovered physician-related and health care professional services—General and administrative.

(1) The medicaid agency evaluates a request for noncovered services in this chapter under WAC 182-501-0160. In addition to noncovered services found in WAC 182-501-0070, except as provided in subsection (2) of this section, the agency does not cover:
(a) Acupuncture, massage, or massage therapy;
(b) Any service specifically excluded by statute;
(c) Care, testing, or treatment of infertility or sexual dysfunction. This includes procedures for donor ovum, donor sperm, gestational carrier, and reversal of vasectomy or tubal ligation;
(d) Hysterectomy performed solely for the purpose of sterilization;
(e) Cosmetic treatment or surgery, except as provided in WAC 182-531-0100 (4)(x);
(f) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 182-501-0165;
(g) Hair transplantation;
(h) Marital counseling or sex therapy;
(i) More costly services when the medicaid agency determines that less costly, equally effective services are available;
(j) Vision-related services as follows:
(i) Services for cosmetic purposes only;
(ii) Group vision screening for eyeglasses; and
(iii) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens correction. This refractive surgery does not include intraocular lens implantation following cataract surgery.
(k) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 182-531-1750;
(l) Physician-supplied medication, except those drugs which the client cannot self-administer and therefore are administered by the physician in the physician's office;
(m) Physical examinations or routine checkups, except as provided in WAC 182-531-0100;
(n) Foot care, unless the client meets criteria and conditions outlined in WAC 182-531-1300, as follows:
(i) Routine foot care including, but not limited to:
(A) Treatment of tinea pedis;
(B) Cutting or removing warts, corns and calluses; and
(C) Trimming, cutting, clipping, or debriding of nails.
(ii) Nonroutine foot care including, but not limited to, treatment of:
(A) Flat feet;
(B) High arches (cavus foot);
(C) Onychomycosis;
(D) Bunions and tailor's bunion (hallux valgus);
(E) Hallux malleus;
(F) Equinus deformity of foot, acquired;
(G) Cavovarus deformity, acquired;
(H) Adult acquired flatfoot (metatarsus adductus or pes planus);
(I) Hallux limitus.
(iii) Any other service performed in the absence of localized illness, injury, or symptoms involving the foot;
(o) Except as provided in WAC 182-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services;
(p) Nonmedical equipment;
(q) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas;
(r) Vaccines recommended or required for the sole purpose of international travel. This does not include routine vaccines administered according to current centers for disease control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States; and
(s) Early elective deliveries as defined in WAC 182-500-0030.
(2) The medicaid agency covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following:
(a) The EPSDT program;
(b) A Washington apple health program for qualified medicare beneficiaries (QMBs); or
(c) A waiver program.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-07-105, § 182-531-0150, filed 3/23/22, effective 4/23/22; WSR 15-24-021, § 182-531-0150, filed 11/19/15, effective 1/1/16; WSR 15-03-041, § 182-531-0150, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0150, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0150, filed 6/29/11, effective 7/30/11; WSR 10-19-057, § 388-531-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0150, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0150, filed 12/6/00, effective 1/6/01.]