10.09.02.06

.06 Preauthorization Requirements.

A. The following procedures or services require preauthorization:

(1) Cosmetic surgery;

(2) Contact lens evaluation and fitting;

(3) Lipectomy and panniculectomy;

(4) Transplantations of vital organs;

(5) Services rendered to an inpatient before one preoperative day;

(6) Surgical procedures for the treatment of obesity;

(7) Surgical procedures for the purpose of gender reassignment; and

(8) Elective services from a noncontiguous state.

B. Services which have been determined by Medicare to be ineffective, unsafe, or without proven clinical value are generally presumed to be not medically necessary, but will be preauthorized if the provider can satisfactorily document medical necessity in a particular case. These services are found in the Medicare Carriers Manual, Part 3, Claims Process, Chapter II, Coverage Issues Appendix.

C. Physicians dispensing or prescribing eyeglasses shall comply with the requirements of COMAR 10.09.14.

D. The Department will preauthorize services when the provider submits to the Department adequate documentation demonstrating that the service to be preauthorized is medically necessary.

E. Preauthorization normally required by the Program is waived when the service is covered and approved by Medicare. Non-Medicare claims require preauthorization according to §§A—D of this regulation.

F. Physicians rendering mental health services shall comply with the preauthorization requirements of COMAR 10.09.70.07.