A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit, each applies to the outpatient setting.
1. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring or machine tests, such as electrocardiograms (ECG).
2. All benefit limits in this section are calculated per State Fiscal Year (SFY: July 1 through June 30).
3. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps.
View or print the essential health benefit procedure codes.
B. Medicaid established a maximum amount (benefit limit) of five hundred dollars ($500) per SFY for diagnostic laboratory services and five hundred dollars ($500) per SFY for radiology/other services, for clients twenty-one (21) years of age.
1. There are no laboratory or radiology/other benefit limits for clients under twenty-one (21) years of age, except for the limitations on fetal echography (ultrasound) and fetal non-stress tests.
2. There is no benefit limit on professional components of laboratory or radiology/other services for hospital inpatient treatment.
3. There is no benefit limit on laboratory services related to family planning. See Section 292.552 for the family-planning-related clinical laboratory procedures exempt from the laboratory services benefit limit.
4. There is no benefit limit on laboratory services or radiology/other services performed as emergency services.
C. Extension-of-benefit requests are considered for medically necessary services.
1. Claims with any of the following primary diagnoses are exempt from laboratory services or radiology/other benefit limits:
a. Malignant neoplasm (View ICD Codes);
b. HIV infection and AIDS (View ICD Codes);
c. Renal failure (View ICD Codes);
d. Pregnancy (View ICD Codes); or
e. Opioid Use Disorder (OUD) when treated with Medication Assisted Treatment (MAT) (View ICD OUD Codes). Designated laboratory tests will be exempt from the laboratory services benefit limit when the diagnosis is OUD. (View Laboratory and Screening Codes).
2. Benefits may be extended for other conditions based on documented reasons of medical necessity. Providers may request extensions of benefits according to instructions in Section 229.100 of this manual.
D. Magnetic resonance imaging (MRI) services are exempt from the five-hundred-dollar ($500) outpatient radiology/other benefit limit. Medical necessity for each MRI must be documented in the client's medical record.
E. Cardiac catheterization procedures are exempt from the five-hundred-dollar ($500) SFY benefit limit (each) for outpatient laboratory services and for radiology/other services. Medical necessity for each procedure must be documented in the client's medical record.
