Regulation .05 Limitations.

The Program does not cover the following:

Services not specified in Regulation .04 of this chapter;

Services not medically necessary;

Investigational and experimental drugs and procedures;

Services denied by Medicare as not medically justified;

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

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);

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

Anesthesia services;

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

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

Ambulance services;

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

Artificial limbs; or

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