Medicine and Surgery Section - Wisconsin.gov

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Appendix PRIOR AUTHORIZATION / PHYSICIAN ATTACHMENT (PA/PA) Page 2 of 2 HCF 11016 (Rev. 01/03) SECTION III — SERVICE INFORMATION A. Describe diagnosis and clinical condition pertinent to service or procedure requested. Bilateral mammary hyperplasia. Patient is 62” tall and weighs 250 lbs. (2.10 m 2 ). Previous treatments consisting of ... have been tried for 3 months and have failed to reduce or alleviate symptoms. B. Describe medical history pertinent to service or procedure requested. Has constant infection and weeping under the mammary fold. 2-3 years of neck and back pain. Bilateral shoulder grooning; unable to perform routine gym exercises, constant rash beneath breasts with seaming and superficial ulceration. C. Supply justification for service or procedure requested. The breast structures are quite heavy and pendulous. In excess of 750 grams will be removed from each breast (per Schneer*). *establish a medical rationale for the procedure with >750 grams/breast with this BSA g 2.10m 2 . D. SIGNATURE — Physician Date Signed MM/DD/YYYY 130 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Appendix 20 Prior Authorization / Physician Attachment (PA/PA) (for photocopying) (A copy of the Prior Authorization/Physician Attachment [PA/PA] is located on the following pages.) Physician Services Handbook — Medicine and Surgery December 2005 131 Appendix
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Physician Services Medicine and Sur
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T Table of Contents Preface .......
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Telemedicine ......................
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Health Professional Shortage Areas
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Legal Framework The following laws
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General Information Treatment (EPSD
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General Information Category III Co
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General Information collecting the
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General Information • The current
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Evaluation and Management reimburse
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Evaluation and Management in an out
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Evaluation and Management 22 Wiscon
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Medicine Services System [HCPCS] co
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Medicine Services In cases where mo
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Medicine Services documentation in
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Medicine Services Providers of ment
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Medicine Services Substance Abuse S
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Surgery Services Appendix 10 of thi
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Surgery Services Cataract Surgery W
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Surgery Services and the insertion
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Surgery Services Note: A telephone
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Surgery Services • Sterilization.
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Surgery Services live with her sinc
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Surgery Services by a multi-discipl
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Prescription Requirements Prescribe
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Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
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Claims Submission 58 Wisconsin Medi
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Reimbursement • Confirming or rev
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Reimbursement about whether a speci
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Reimbursement 64 Wisconsin Medicaid
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Appendix 66 Wisconsin Medicaid and
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Appendix Surgery Services Appendix
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Appendix Medicine Services (Continu
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Appendix Other Services Appendix 1
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Appendix Appendix 4 (Continued) If
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Page 86 and 87: Appendix 84 Wisconsin Medicaid and
Page 96 and 97: Appendix (This page was intentional
Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
Page 122 and 123: Appendix SECTION II — RECIPIENT I
Page 136 and 137: PRIOR AUTHORIZATION / PHYSICIAN ATT
Page 140 and 141: PRIOR AUTHORIZATION / “J” CODE
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Page 148 and 149: PRIOR AUTHORIZATION / PHYSICIAN OTO
Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
Page 158 and 159: Appendix Appendix 26 (Continued) ma
Page 160 and 161: Appendix The following table lists
Page 172 and 173: DECLARATION OF SUPERVISION FOR NONB
Page 176 and 177: Appendix HCPCS Code* Drug Name Diag
Page 178: Index Organ Transplants, 44 Provide
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Medicine and Surgery Section - Wisconsin.gov

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