Regulation .04 Covered Services.

Medically necessary facility services rendered to recipients in a free-standing Medicare-certified ambulatory surgical center;

Diagnostic, curative, palliative, or rehabilitative services, when clearly related to the recipient's individual needs;

Surgical procedures which meet the standards described in 42 CFR Part 416, Subpart D, §416.65, and as published by the Centers for Medicare and Medicaid Services; and

Dental services that have been pre-authorized by the Dental Benefits Administrator (DBA).