Sec. 10.09.42.05. 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. Services denied by Medicare as not medically justified;

E. Separate billing of services which are included in the composite Medicare rate for an ambulatory surgical center;

F. Surgical procedures which:

(1) Generally result in extensive blood loss;

(2) Require major or prolonged invasion of body cavities;

(3) Directly involve major blood vessels;

(4) Are generally emergency or life-threatening in nature;

(5) Commonly require systemic thrombolytic therapy;

(6) Are designated as requiring inpatient care (overnight);

(7) Can only be reported using a CPT unlisted surgical procedure code; or

(8) Are otherwise excluded under 42 CFR §411.15(a)-(h) and (j)-(s);

G. Physicians' services, including surgical procedures and all preoperative and postoperative services performed by a physician;

H. Anesthesia services;

I. Radiology services other than those integral to performance of a covered surgical procedure;

J. Diagnostic procedures other than those directly related to a covered surgical procedure;

K. Ambulance services;

L. Leg, arm, back, and neck braces other than those that serve the function of a cast or splint;

M. Artificial limbs; or

N. Non-implantable prosthetic devices and durable medical equipment (DME).