7 AAC 105.110 - Noncovered services
Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for a service that is
(1) not reasonably necessary for the
diagnosis and treatment of an illness or injury, or for the correction of an
organic system, as determined upon review by the department or that is not
identified in a screening required under
7
AAC 110.205;
(2) not properly prescribed or medically
necessary in accordance with criteria established under 7 AAC 105 - 7 AAC 160
or by standards of practice applicable to the prescribing provider;
(3) incurred for an evaluative or periodic
checkup, examination, or immunization
(A) that
is in connection with the participation, enrollment, attendance, or
accomplishment of a program or activity unrelated to the recipient's physical
or mental health or rehabilitation; or
(B) unless it is
(i) an adult preventive service covered under
7
AAC 110.800;
(ii) part of an EPSDT screening; or
(iii) required by the department for the
purpose of determining eligibility for Medicaid;
(4) for or in connection with cosmetic
therapy or plastic or cosmetic surgery, including rhinoplasty, nasal
reconstruction, excision of keloids, augmentation mammoplasty, silicone or
silastic implants, facioplasty, osteoplasty (prognathism and micronathism),
dermabrasion, skin grafts, and lipectomy; however, coverage is available if
required for the following corrective actions if performed within the normal
course of treatment or otherwise beginning no later than one year after birth
or the event that caused the need for the corrective action:
(A) repair of an injury;
(B) improvement of the functioning of a
malformed body member;
(C)
correction of a visible disfigurement that would materially affect the
recipient's acceptance in society;
(5) a nonmedical charge imposed by a
recipient's friend or relative;
(6)
for a person who is in the custody of the federal, state, or local law
enforcement, including a juvenile in a detention or correctional facility,
except as an inpatient in a medical institution;
(7) for an experimental or investigational
service, except for covered routine patient costs associated with clinical
trials specified in 42
U.S.C. 1396d(gg)(1), adopted
by reference in
7
AAC 160.900; for the purposes of this paragraph, an
experimental or investigational service for which the department will not pay
includes one
(A) that is in a phase I or II
clinical trial as defined in the United States Department of Health and Human
Services, National Institutes of Health, Glossary of Terms for Human
Subjects Protection and Inclusion Issues, adopted by reference in
7
AAC 160.900;
(B) for which inadequate available clinical
or preclinical data exists to provide a reasonable expectation that the
proposed service is at least as safe and effective as one not under experiment
or investigation;
(C) for which an
expert has issued an opinion that additional information is needed to assess
the safety or efficacy of the proposed service;
(D) for which final approval from the
appropriate governmental body has not been granted for the specific indications
for which the use of the service is being proposed; however, if a drug has
received final approval from the United States Food and Drug Administration
(FDA) for any indication, final approval is not required for the specific
indication for which use is being proposed if
(i) the prescription or order was issued by a
licensed health care provider within the scope of the provider's
license;
(ii) prior authorization
was obtained from the department if required under 7 AAC 105 - 7 AAC 160;
or
(iii) the condition being
treated with the drug is not otherwise excluded as a use of the drug;
or
(E) whose use is not
in accordance with customary standards of medical practice;
(8) for missed appointments; however, the
provider may charge the recipient;
(9) for interpreter services;
(10) for infertility services;
(11) for impotence therapy and
services;
(12) Repealed
7/25/2021.
(13) for sterilization
for recipients under 21 years of age and hysterectomies performed solely for
sterilization purposes;
(14) for
nonsurgical weight reduction or maintenance treatment programs and
products;
(15) for nonmedical
fitness maintenance centers and services;
(16) for educational services or supplies
that are separately identifiable in the United States Department of Health and
Human Services, Centers for Medicare and Medicaid Services' (CMS)
Healthcare Common Procedure Coding System (HCPCS), adopted by
reference in
7
AAC 160.900;
(17) an alternative therapy or other service
including acupuncture, homeopathic or naturopathic remedy, or Ayurvedic
medicine;
(18) an outpatient drug
for which payment under the United States Department of Health and Human
Services, Centers for Medicare and Medicaid Services' drug rebate program
established in 42 U.S.C.
1396r-8 is not available;
(19) for which the recipient does not meet
the eligibility requirements for that service under 7 AAC 100; or
(20) after the recipient's date of
death.
Notes
Authority: AS 47.05.010
AS 47.07.030
AS 47.07.040
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.