Title: Section 85.1 - Emergency or urgent surgery
LIMITATIONS ON HOSPITALIZATION, INCLUDING SURGERY
Section 85.1 Emergency or urgent surgery. (a) To be a covered benefit under medical assistance for the needy as provided in section 365-1(5)(a) of the Social Services Law, any emergency or urgent surgery shall be for alleviation of severe pain or for the immediate diagnosis and/or treatment of conditions which threaten disability or death if not promptly diagnosed or treated. No such emergency or urgent surgery requires prior determination of coverability.
In each case, a person designated by the Commissioner of Health shall determine coverability of this benefit based upon the documented existence of one or more conditions such as the following:
(1) obstetrical crises and/or labor;
(2) acute trauma;
(3) reparative or reconstructive surgical procedures performed within 60 days of acute trauma;
(4) malignancy, confirmed or suspected;
(5) hemorrhage or threat of hemorrhage;
(6) serious infection;
(7) severe pain;
(8) shock or impending shock;
(9) decompensated vital functions or threat to vital functions such as sensorium, respiration, circulation, excretion and sensory organs;
(10) congenital defects or abnormalities in a newborn infant best managed by prompt intervention;
(11) any condition the management of which requires prompt diagnostic procedures necessarily performed on an inpatient basis such as biopsy and endoscopy; or
(12) any other condition which causes severe pain or threatens disability or death if not promptly diagnosed or treated.
(b) The first three days of inpatient care, services and supplies for persons admitted to inpatient hospital care under this section shall be deemed a covered benefit under medical assistance for the needy. To be a covered benefit after the third day of inpatient care, there shall be a determination of benefit coverability prior to the end of the third day by a person designated by the Commissioner of Health. Such initial determination shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in section 85.5(a) of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of coverability shall be based upon the existence of one or more conditions such as those listed in subdivision (a) of this section which can be treated only on an inpatient hospital basis, as documented in the patient's medical record. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part.
(c) Determination of benefit coverability under this section shall be made by a designated physician or nonphysician under a designated physician's supervision. A determination of noncoverability shall be made only by a designated physician. If such determination of noncoverability is made, any care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.
(d) Notice of determination shall be given to the patient's surgeon, the hospital administrator and, if there is a determination of noncoverability, to the patient. The hospital shall keep any such notification on file, accessible for review by representatives of the State or of the local social services district. The patient's surgeon or hospital administrator may, within three days of the date of such notification, appeal a determination of noncoverability in writing to the physician or physicians designated by the commissioner for such purpose. Notification of the decision on appeal shall be given to the patient's surgeon, the hospital administrator and the patient. If the determination of noncoverability is affirmed on appeal, any inpatient hospital care, supplies or services provided beyond three days shall not be a covered benefit.
(e) If the person designated by the Commissioner of Health decides in the course of making determinations of coverability under this section or it is determined from other sources that a physician, physicians or the hospital are admitting patients under this section for medical conditions which are not for alleviation of severe pain or for the immediate diagnosis and/or treatment of conditions which threaten disability or death if not promptly diagnosed or treated, the designated person shall give written notification to the physician(s) and the hospital that if such admissions continue, the initial three-day period of stay will no longer be deemed a covered benefit. If patients are thereafter admitted for medical conditions which are not for the aforesaid purposes, the designated person shall notify the physician(s) and the hospital that to be a covered benefit, the first three days of inpatient stay will be subject to a determination of coverability. Such determination of coverability shall be made prior to the end of the third day of inpatient hospital stay in accordance with the procedures in subdivisions (a), (b), (c) and (d) of this section. If there is a determination of non-coverability, any inpatient hospital care, supplies or services provided shall not be a covered benefit under medical assistance for the needy.
VOLUME A-1a (Title 10)