section .0400 – other services

 

10A NCAC 25P .0401        PHYSICIAN SERVICES

(a)  Injection shall not be covered when oral

drugs may be used in lieu of injection.

(b)  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; and

(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); 108A‑54;

108A‑55; 42 C.F.R. 440.50; 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; January 1, 1986;

Transferred from 10A NCAC 22O .0404 Eff. May 1, 2012.