7 AAC 43.010. Exclusions

Unless otherwise provided in this chapter, the department will not pay for a medical expense 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;

(2) for an item or service not properly prescribed or determined necessary by a health care practitioner;

(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;

(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 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;

(5) a non-medical charge imposed by a recipient's friend or relative;

(6) for a person who is in the care and custody of a federal, state, or local correctional facility, including a juvenile under a court order in a detention facility;

(7) for experimental and investigational procedures, items, supplies, drugs, and services, including

(A) diagnostic or therapeutic procedures for research, or educational purposes; and

(B) services that are not in accordance with customary standards of medical practice or not commonly used;

(8) for interpreter services;

(9) for infertility services;

(10) for impotence therapy and services;

(11) for treatment, therapy, surgery, or other procedures related to gender reassignment;

(12) for sterilization for recipients under 21 years of age and hysterectomies performed solely for sterilization purposes;

(13) for non-surgical weight reduction or maintenance treatment programs and products;

(14) for non-medical fitness maintenance centers and services; or

(15) 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's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005 , as amended from time to time, and adopted by reference; or

(B) Alternative Link's ABC Coding Manual for Integrative Healthcare , 7th edition, 2005 first release, adopted by reference.

History: Eff. 8/18/79, Register 71; readopt 8/7/96, Register 139; am 11/1/2000, Register 156; am 6/24/2004, Register 170; am 12/2/2005, Register 176

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: The United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005 , adopted by reference in 7 AAC 43.010, may be obtained by contacting the Superintendent of Documents, United States Government Printing Office, Washington, D.C. 20402. A copy of the HCPCS is available for examination at the Department of Health and Social Services, Division of Health Care Services, 350 Main St., Juneau, Alaska 99801.

Alternative Link's ABC Coding Manual for Integrative Healthcare , adopted by reference in 7 AAC 43.010, may be obtained from Alternative Link, 6121 Indian School Road NE, Suite 131, Albuquerque, NM 87110; telephone: (505) 875-0001, toll free: (877) 621-5465; fax: (505) 875-0002; or at the following Internet address: http://www.alternativelink.com/ali/contact us/. A copy of the ABC Coding Manual for Integrative Healthcare is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.

Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.010 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

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