Sec. 10.09.09.05. Limitations

The following are not covered:

A. Services for which the medical laboratory provider cannot supply a properly completed order or standing order identifying the individual practitioner who ordered the laboratory services;

B. Services not adequately documented in the recipient's medical records;

C. Services denied by Medicare as not medically necessary;

D. Clinical laboratory services, for which certification by HCFA under CLIA is required, when these services are performed by laboratories that are not certified to perform those services;

E. Procedures that the provider knows or should know are investigational or experimental in nature;

F. Services included by the Program as part of the charge made by an inpatient facility, hospital outpatient department, freestanding clinic, or other Program-recognized entity;

G. Medical laboratory services related to autopsies;

H. Medical laboratory services for which there was insufficient quantity of specimen, improper specimen handling, or other circumstances that would render the results unreliable; and

I. Laboratory services ordered by an:

(1) Individual who is not enrolled as a provider in the Program with an active status on the date of service; and

(2) Entity, facility, or another provider that is not an individual.