Sec. 10.09.08.06. Limitations

The Program does not cover the following:

A. Services not specified in Regulation .04 of this chapter;

B. Services not medically necessary;

C. Investigational and experimental drugs and procedures;

D. Procedures solely for cosmetic purposes;

E. Services denied by Medicare as not medically justified;

F. Freestanding clinic services for inpatient recipients in State-operated facilities serving individuals with intellectual disabilities;

G. Freestanding clinic services provided to hospital inpatients;

H. Freestanding clinic visits when patients are referred to hospital outpatient departments or emergency rooms for services ordinarily provided in freestanding clinics covered by this chapter;

I. Freestanding clinic visits solely for the purpose of one or more of the following:

(1) Prescription drugs or collection of laboratory specimens, unless otherwise allowed;

(2) Certification or recertification of food supplements;

(3) Performing laboratory tests required only for certification or recertification of food supplement programs;

(4) Nutritional assessments in the absence of diagnosis of nutritional disorders, unless EPSDT or primary health services are provided at the same time;

(5) Ascertaining the patient's weight;

(6) Interpretation of laboratory tests or panels; and

(7) Measurement of blood pressure;

J. Injections and visits solely for the administration of injections, unless medical necessity and the recipient's inability to take appropriate oral medications are documented in the patient's medical record;

K. More than one visit per day to the same freestanding clinic, unless the additional visit is adequately documented as:

(1) An emergency situation; or

(2) A visit to a different specialty;

L. Central nervous system stimulants and anorectic agents when used for weight control;

M. Immunizations required for travel outside the continental United States;

N. Vision care services excluded under COMAR 10.09.14 or COMAR 10.09.23;

O. Separate billing for services which are specifically included as part of another service;

P. Separate reimbursement to a physician for services provided in a freestanding clinic in addition to the freestanding clinic reimbursement;

Q. Payment for more than one visit to complete an EPSDT screening service;

R. Visits solely for group or individual health education;

S. Freestanding clinic visits in addition to an EKG procedure when the EKG procedure is the only purpose for the visit; and

T. Services for which preauthorization is required under Regulation .09 of this chapter but has not been obtained.