10A NCAC 39A .1104. COVERED SERVICES

(a)  Covered services shall include diagnostic and treatment services for cancer or a condition suggestive of cancer.  Physical therapy following surgery, where medically indicated, is an approved treatment service.

(b)  Service restrictions:

(1)           Dental treatment is not covered except in cases of head and neck cancer when necessary for the delivery of oncologic care.

(2)           The Program shall not cover late discharge fees, transportation, telephone calls, or other miscellaneous charges.

(3)           Cosmetic surgery shall not be covered.  This does not preclude the coverage of reconstructive surgery for patients for whom the Program has paid for a treatment service related to their current diagnosis.

(4)           Ancillary diagnostic studies shall be authorized only when they are determined by the Program to be directly related to the confirmation of a diagnosis of cancer or are necessary for treatment planning.

(5)           The Program may authorize reimbursement for up to two follow-up office visits after completion of diagnostic studies or treatment.  These visits shall be included within the days allowed for diagnostic and treatment services.

(6)           Treatment for patients suspected of having cervical intraepithelial neoplasia shall be performed in accordance with the guidelines of the American College of Obstetricians and Gynecologists (ACOG) contained in Technical Bulletin Number 183 - August 1993, which is incorporated herein by reference in accordance with G.S. 150B-21.6, along with any subsequent amendments and editions.  Copies of the guidelines may be obtained at no cost by calling [phone] or by writing to the Cancer Control Program, 1915 Mail Service Centeer, Raleigh, NC 27699-1915.

(7)           The use of any course of treatment not recognized as having scientifically established medical value nor accepted as standard medical treatment for the condition being treated, as determined by the Program, will not be covered.

(8)           Inpatient services shall not be authorized unless the hospital is licensed in the State of North Carolina under General Statute 131E-5, the Hospital Licensure Act, or under conditions of participation for Medicare (Title XVIII of the Social Security Act) or Medicaid (Title XIX of the Social Security Act).

(c)  Meals and overnight accommodations, in a motel, home, boarding house, ambulatory care facility, or similar facility for patients receiving covered services on an outpatient basis shall be covered by the Program if the patient's residence is at least 50 miles from the medical facility providing the outpatient services.

(1)           Reimbursement for actual expenses shall not exceed the maximum allowable subsistence (meals and accommodations) for state employees in the course of their official duties, found in G.S. 138-6, based on those rates of reimbursement in effect at the time of the authorization of these expenses by the Program.

(2)           Program authorization of meals and accommodations shall be limited to the maximum number of days of service coverage.  However, the Program shall cover meals and accommodations for weekends between the periods during which treatment is authorized.

(3)           Authorization Requests for meals and accommodations shall state the number of days which will be required, as well as the dates of service on which outpatient diagnostic or treatment services shall be rendered.

 

History Note:        Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Authority G.S. 130A‑205;

Eff. April 1, 1993;

Amended Eff. August 1, 2000; August 1, 1995.