Wyoming Medicaid Changes Pre-Authorization Rules for Some Procedures

By Wyoming Medical Society Staff

CHEYENNE – Wyoming Medicaid has changed some rules as it relates to pre-authorizations for pediatric procedures. According to Sheree Nall, CPC of the Wyoming Department of Health, effective Sept. 1, 2016, removal of skin tags and benign lesions will no longer require prior authorization.  The codes included are 11200-11201, 11300-11312, 11400-11446, and 17106-17111. Post pay review will be conducted to verify medical necessity of the procedures billed.

During any post pay review, Nall said Wyoming Medicaid will be looking for medical necessity for the procedure completed i.e. intense itching, burning, irritation, pain, tenderness, chronic, recurrent or persistent bleeding, physical evidence of inflammation to show that the procedure was not cosmetic.

Amy Buxton of The Wyoming Department of Health also reported at the he May 11, 2016 meeting of the Pharmacy and Therapeutics Committee, committee members voted to lift the ADHD diagnosis requirement for Medicaid clients age 4-17 years. This change became effective on June 22, 2016.

Consequently, a PA is not required for stimulant medications for Medicaid clients age 4-17 in order to establish and ADHD diagnosis. A PA will still be required for stimulant medication for clients under age 4 or age 18 or greater. Additionally, if a provider is prescribing a stimulant medication at a dose greater than the  Medicaid maximum dose, a PA will be required. Dose limitations and other PA information can be found at www.wymedicaid.org.

The executive committee of the Wyoming chapter of the AAP also sought clarity on the issue of a monthly referral for OT/PT/ST. Buxton said the state rule in the past has been for prescriptions and orders for OT/PT/ST to be updated every 30 days. That has changed.

“Effective January 1st, 2017, this rule is being updated to state that the plan of care or prescription/order can be valid for up to 180 days,” Buxton wrote.