10A NCAC 25P .0301. OUTPATIENT HOSPITAL SERVICES

(a)  Injection of medications that can be administered orally shall not be covered.

(b)  Provision of durable medical equipment shall not be covered.

(c)  Take‑home legend drugs shall not be provided, except when dispensed during hours when pharmacies are not open for business.

(d)  Non‑legend drugs shall not be covered.

(e)  Immunization shall not be covered.

(f)  Coverage for selected elective surgical procedures is contingent upon the rendering of a second opinion by another qualified practitioner when Medicaid is the primary payor.  Categories of surgery which may be subject to a second surgical opinion requirement include hysterectomy, cholocystectomy, hemorrhoidectomy, knee surgery, coronary bypass, foot surgery, laminectomy, prostatectomy, tonsillectomy and adenoidectomy, inguinal hernia repair, varicose vein stripping and cataract surgery.  This requirement may be waived by the state agency under the following conditions:

(1)           Subsequent to the performance of the procedure the recipient is determined to be retroactively eligible;

(2)           Unanticipated circumstances precluded performance of a second surgical opinion;

(3)           Physician developed criteria precludes a second opinion.

In all cases the final decision to perform the surgery rests with the recipient.  A third opinion is covered but not required.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.20; 42 C.F.R. 440.230(d); 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986;

Transferred from 10A NCAC 22O .0402 Eff. May 1, 2012.