(1) Except as provided in WAC 388-531-0100
and subsection (2) of this section, the department does not cover the following:
(a) Acupuncture, massage, or massage therapy;
(b) Any service specifically excluded by statute;
(c) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation;
(d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness;
(e) 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 388-501-0165
(f) Hair transplantation;
(g) Marital counseling or sex therapy;
(h) More costly services when the department determines that less costly, equally effective services are available;
(i) 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.
(j) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 388-531-1750
(k) Physician-supplied medication, except those drugs administered by the physician in the physician's office;
(l) Physical examinations or routine checkups, except as provided in WAC 388-531-0100
(m) Foot care, unless the client meets criteria and conditions outlined in WAC 388-531-1300
, as follows:
(i) Routine foot care, such as 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, such as, but not limited to treatment of:
(A) Flat feet;
(B) High arches (cavus foot);
(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;
(n) Except as provided in WAC 388-531-1600
, 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.
(o) Nonmedical equipment;
(p) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas;
(q) Bilateral cochlear implantation; and
(r) Routine or nonemergency medical and surgical dental services provided by a doctor of dental medicine or dental surgery for clients twenty one years of age and older, except for clients of the division of developmental disabilities.
(2) The department 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 medicaid program for qualified medicare
beneficiaries (QMBs); or
(c) A waiver program.
[11-14-075, recodified as § 182-531-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 11-14-055, § 388-531-0150, filed 6/29/11, effective 7/30/11; 10-19-057, § 388-531-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, § 388-531-0150, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-0150, filed 12/6/00, effective 1/6/01.]