Request for NEW Consideration of Medical & Dental Benefit Coverage for Louisiana Medicaid

Providers and vendors may request that Louisiana Medicaid consider coverage of a new service, technology or other benefit. Please fill out and submit a request for consideration form in order to propose a new benefit for review and consideration of coverage.

Services that are experimental, non-FDA approved, investigational or cosmetic will not be considered for coverage.  A service may be deemed medically necessary and still not be covered under the Medicaid Program.  The Medicaid Director, in consultation with the Medicaid Medical Director, may consider authorizing services at her discretion on a case-by-case basis.

Please attach supporting documentation, such as publications, bibliography, and/or other evidence-based documents to a completed request for new consideration for a benefit to be considered for coverage by Louisiana Medicaid.

Relevant research studies submitted should be free of industry bias and non-industry supported.

Provide as much information by answering the following questions as completely and as accurately as possible.

Contact Information

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Procedure, Treatment, Medication, or Device Information

What is the name of the procedure, treatment, medication, or device that you would like considered for coverage?

Provide a brief description of the treatment, procedure, medication, or device that you would like considered for coverage (please include billing codes, if known).

Provide a brief description of current alternative treatments, procedures, medication, or devices (please include billing codes, if known).

What are the patient populations covered by this request?

What are the desired and/or expected outcomes? (e.g., improved survival, decreased need for hospitalization) Provide data.

What types of providers would use this intervention? (e.g., type of physician, physician assistant, advanced practice nurses, therapist: PT, ST, OT)