WAC 388-501-0070   Healthcare coverage -- Noncovered services.  (1) The department does not pay for any service, treatment, equipment, drug or supply not listed or referred to as a covered service in WAC 388-501-0060, regardless of medical necessity. Circumstances under which clients are responsible for payment of services are described in WAC 388-502-0160.

     (2) This section does not apply to services provided under the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 388-534 WAC.

     (3) The department does not pay for any ancillary service(s) provided in association with a noncovered service.

     (4) The following list of noncovered services is not intended to be exhaustive. Noncovered services include, but are not limited to:

     (a) Any service specifically excluded by federal or state law;

     (b) Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, naturopathy, and sanipractice;

     (c) Chiropractic care for adults;

     (d) Cosmetic, reconstructive, or plastic surgery, and any related services and supplies, not specifically allowed under WAC 388-531-0100(4).

     (e) Ear or other body piercing;

     (f) Face lifts or other facial cosmetic enhancements;

     (g) Gender reassignment surgery and any surgery related to transsexualism, gender identity disorders, and body dysmorphism, and related services, supplies, or procedures, including construction of internal or external genitalia, breast augmentation, or mammoplasty;

     (h) Hair transplants, epilation (hair removal), and electrolysis;

     (i) Fertility, infertility or sexual dysfunction testing, care, drugs, and treatment including but not limited to:

     (i) Artificial insemination;

     (ii) Donor ovum, sperm, or surrogate womb;

     (iii) In vitro fertilization;

     (iv) Penile implants;

     (v) Reversal of sterilization; and

     (vi) Sex therapy.

     (j) Marital counseling;

     (k) Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;

     (l) Nonmedical equipment;

     (m) Penile implants;

     (n) Prosthetic testicles;

     (o) Psychiatric sleep therapy;

     (p) Subcutaneous injection filling;

     (q) Tattoo removal;

     (r) Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities; and

     (s) Vehicle purchase - new or used vehicle.

     (5) For a specific listing of noncovered services in the following service categories, refer to the accompanying WAC citation:

     (a) Ambulance transportation as described in WAC 388-546-0250;

     (b) Dental services (for clients twenty-one years of age and younger) as described in chapter 388-535 WAC;

     (c) Dental services (for clients twenty-one years of age and older) as described in chapter 388-535 WAC;

     (d) Durable medical equipment as described in WAC 388-543-1300;

     (e) Hearing care services as described in WAC 388-544-1400;

     (f) Home health services as described in WAC 388-551-2130;

     (g) Hospital services as described in WAC 388-550-1600;

     (h) Physician-related services as described in WAC 388-531-0150;

     (i) Prescription drugs as described in WAC 388-530-1150; and

     (j) Vision care services as described in WAC 388-544-0475.

     (6) A client has a right to request an administrative hearing when a service is denied as noncovered. When the department denies all or part of a request for a noncovered service(s) or equipment, the department sends the client and the provider written notice, within ten business days of the date the decision is made, that includes:

     (a) A statement of the action the department intends to take;

     (b) Reference to the specific WAC provision upon which the denial is based;

     (c) Sufficient detail to enable the recipient to:

     (i) Learn why the department's action was taken; and

     (ii) Prepare a response to the department's decision to classify the requested service as noncovered.

     (d) The specific factual basis for the intended action;

     (e) The following information:

     (i) The client's administrative hearing rights;

     (ii) Instructions on how to request the hearing;

     (iii) Acknowledgement that a client may be represented at the hearing by legal counsel or other representative;

     (iv) Upon the client's request, the name and address of the nearest legal services office;

     (v) Instructions on how to request an exception to rule (ETR); and

     (vi) Information regarding department-covered services, if any, as an alternative to the requested noncovered service.

     (7) A client can request an ETR as described in WAC 388-501-0160.



[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-04-036, § 388-501-0070, filed 1/29/07, effective 3/1/07.]