Section R9-22-215. Other Medical Professional Services

A.      The following medical professional services are covered ser- vices if a member receives these services in an inpatient, out- patient, or office:

1.        Dialysis;

2.        The following family planning services if provided to delay or prevent pregnancy:

a.         Medications,

b.        Supplies,

c.         Devices, and

d.        Surgical procedures;

3.        Family planning services are limited to:

a.         Contraceptive counseling, medications, supplies, and associated medical and laboratory examinations, including HIV blood screening as part of a package of sexually transmitted disease tests provided with a family planning service;

b.        Sterilization; and

c.         Natural family planning education or referral;

4.        Midwifery services provided by a certified nurse practi- tioner in midwifery;

5.        Midwifery services for low-risk pregnancies and home deliveries provided by a licensed midwife;

6.        Respiratory therapy;

7.        Ambulatory and outpatient surgery facilities services;

8.        Home health services under A.R.S. § 36-2907(D);

9.        Private or special duty nursing services;

10.     Rehabilitation services including physical therapy, occu- pational therapy, speech therapy, and audiology within limitations in subsection (C);

11.     Total parenteral nutrition services, which are the provi- sion of total caloric needs by intravenous route for indi- viduals with severe pathology of the alimentary tract; and

12.     Chemotherapy.

B.       Prior authorization from the Administration for a member is required for services listed in subsections (A)(3)(b), and (A)(4) through (11); except for:

1.        Voluntary sterilization;

2.        Dialysis shunt placement;

3.        Arteriovenous graft placement for dialysis;

4.        Angioplasties or thrombectomies of dialysis shunts;

5.        Angioplasties or thrombectomies of arteriovenous grafts for dialysis;

6.        Eye surgery for the treatment of diabetic retinopathy;

7.        Eye surgery for the treatment of glaucoma;

8.        Eye surgery for the treatment of macular degeneration;

9.        Home  health  visits  following  an acute hospitalization (limited up to five visits);

10.     Hysteroscopies (up to two, one before and one after) when associated with a family planning diagnosis code and done within 90 days of hysteroscopic sterilization;

11.     Physical therapy subject to the limitation in subsection (C);

12.     Facility services related to wound debridement,

13.     Apnea management and training for premature babies up to the age of 1; and

14.     Other services identified by the Administration through the Provider Participation Agreement.

C.      The following are not covered services:

1.        Occupational and speech therapies provided on an outpa- tient basis for a member age 21 or older;

2.        Abortion counseling;

3.        Services or items furnished solely for cosmetic purposes;

4.        Services provided by a podiatrist; or

5.        More than 15 outpatient physical therapy visits per bene- fit year for persons age 21 years or older for the purpose

of restoring a skill or level of function and maintaining that skill or level of function once restored.

6.        More than 15 outpatient physical therapy visits per bene- fit year for persons age 21 years or older for the purpose of acquiring a new skill or a new level of function and maintaining that skill or level of function once acquired.

Historical Note

Adopted as an emergency effective May 20, 1982 pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-215 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective Octo-

ber 1, 1985 (Supp. 85-5). Section repealed, new Section

adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by final

rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 16

A.A.R. 1638, effective October 1, 2010 (Supp. 10-3). Amended by final rulemaking at 17 A.A.R. 1658, effec-

tive August 2, 2011 (Supp. 11-3). Amended by final

rulemaking at 20 A.A.R. 1949, effective September 6,

2014 (Supp. 14-3).