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Title: Section 85.4 - One-day presurgical stay limitation

85.4 One-day presurgical stay limitation.

(a) To be a covered benefit under medical assistance for the needy, provided in section 365-a(5)(d) of the Social Services Law, any presurgical hospital stay of more than one day for surgical benefits covered by sections 365-a(5)(b) and 365-a(5)(c) shall require a determination of coverability prior to admission by a person designated by the Commissioner of Health. Such determination of coverability shall be for a specified maximum period of presurgical stay. A written request for such determination shall be made by the patient's surgeon, proposing the total length of presurgical stay, and citing conditions requiring such exceptional stay. A determination of coverability shall be based upon existence of conditions which require inpatient preparation of more than one day to improve operative risk status such as:

(1) correction of significant fluid or electrolyte imbalance.

(2) transfusion to correct significant anemia.

(3) stabilization of congestive heart failure.

(4) improvement of pulmonary function or drainage.

(5) hyperalimentation to correct significant malnutrition.

(6) gastrointestinal preparation before gastrointestinal surgery.

(7) stabilization of significant endocrine disorder.

(8) hematologic and immunologic preparation for organ transplant.

(9) management of infection.

(10) essential preliminary studies and procedures performable only on an inpatient basis.

(b) Determination of coverability shall be made by a designated physician or non-physician under physician supervision. A determination of non-coverability shall be made only by a designated physician. Notice of determination shall be given to the patient's physician who shall, in case of extended coverability, incorporate such notice in the patient's medical record at admission. No presurgical stay of more than one day will be a covered benefit without such prior determination of coverability and its incorporation in the patient's medical record.

(c) The patient's physician may appeal any determination of non-coverability to a physician or physicians designated by the commissioner for such purpose. Notification of decision on appeal shall be given to the patient's physician, who shall incorporate such notification in the patient's medical record at admission.


VOLUME A-1a (Title 10)