S.D. Admin. R. 67:16:01:08

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:01:08 - Services not covered

In addition to items and services specified as not covered in other sections of this article, the following items and services are not covered under the medical assistance program:

(1) Items or services which have been determined by the state dental or medical consultant or through peer reviews to be not medically necessary, safe, or effective;

(2) Items or services for which the recipient has no legal obligation to pay or which are charges imposed by immediate relatives or members of the recipient's household;

(3) Over-the-counter drugs, home remedies, food supplements, nutritional items, vitamins, or alcoholic beverages, except as covered under chapter 67:16:14 or 67:16:42;

(4) Diagnosis or treatment given in the absence of the patient;

(5) Cosmetic surgery to improve the appearance of an individual, if not incidental to prompt repair following an accidental injury or any cosmetic surgery that goes beyond that which is necessary to improve the functioning of a malformed body member;

(6) Items or services provided by practitioners or agencies in the employ of or under contract with the federal, state, or local government, except state institutions for the developmentally disabled that are certified as skilled nursing or intermediate care facilities, the state psychiatric hospital, the public health service, or the national health service;

(7) Organ transplants, except as authorized under chapter 67:16:31;

(8) Acupuncture;

(9) Biofeedback;

(10) Chronic pain rehabilitation program services or chronic pain management services, except as allowed under chapter 67:16:14;

(11) Alcohol and drug rehabilitation therapy, except for services provided under chapter 67:16:48;

(12) Procedures for implanting an embryo;

(13) Gastric bypass, gastric stapling, gastroplasty, any similar surgical procedure, or the associated conservative weight loss management unless prior authorized;

(14) Self-help devices, exercise equipment, protective outerwear, personal comfort services or environmental control equipment, such as air conditioners, humidifiers, dehumidifiers, heaters, or furnaces;

(15) Medical equipment for a resident in a health care facility, except as authorized under chapter 67:44:03;

(16) Autopsies;

(17) Custodial care, except as authorized under chapter 67:44:03;

(18) Nursing facility services for individuals age 21 and over and under age 65 in institutions for mental disease;

(19) Broken appointments;

(20) Reports required solely for insurance or legal purposes unless requested by the department, the Department of Health, or the Department of Human Services;

(21) Concurrent care by more than one provider of the same discipline for the same diagnosis without a medical referral detailing the medical necessity of the concurrent care. For concurrent care without medical referral, the department will pay only the first claim submitted;

(22) A health service that is not documented in the recipient's medical record as required by chapter 67:16:34;

(23) Vocational training, educational activities, teaching, or counseling, except outpatient diabetes self-management education programs covered under chapter 67:16:46;

(24) Record keeping, charting, or documentation related to providing a covered service, unless specifically allowed in this article;

(25) Payment of mileage unless specifically covered under this article;

(26) Drugs and biologicals, which the federal government has determined to be less than effective, as listed in § 67:16:14:05;

(27) Services, procedures, or drugs, which are considered experimental by the United States Department of Health and Human Services or another federal agency. However, services, procedures, or drugs that are approved for emergency use authorization are not considered experimental;

(28) Procedures and services to reverse sterilization;

(29) Computers, computer hookups, or computer printers, unless prior authorized;

(30) Gambling addiction services or therapy; and

(31) Penile implants.

S.D. Admin. R. 67:16:01:08

SL 1975, ch 16; 43 SDR 80, effective 12/5/2016; 46 SDR 050, effective 10/10/2019; 47 SDR 129, effective 6/3/2021

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1)(2).

Covered services must be medically necessary, § 67:16:01:06.02.