Section 7.105.110. 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) for a mammogram;  
				(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 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, including 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) for treatment, therapy, surgery, or other procedures related to gender reassignment;  
		(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  
			(A) 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; or  
			(B) Alternative Link's ABC Coding Manual for Integrative Healthcare, 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.  

Authorities

47.05.010;47.07.030;47.07.040

Notes

Reference

7 AAC 120.112
7 AAC 140.315
7 AAC 150.180

Authority

AS 47.05.010 AS 47.07.030 AS 47.07.040

History

Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 5/11/2012, Register 202; am 9/20/2015, Register 215; am 5/1/2016, Register 218