Authority: IC 12-15

Affected: IC 12-13-7-3

Sec. 1. The following services are not covered by Medicaid:

1. (1) Services that are not medically necessary.
2. (2) Services provided outside the scope of a provider's license, registration, certification, or other authority to practice under state or federal law.
3. (3) Experimental drugs, treatments, or procedures, and all related services.
4. (4) Any new product, service, or technology not specifically covered in this article. The product, service, or technology will remain a noncovered product, service, or technology until such time as the office authorizes the coverage of the product, service, or technology. This subdivision does not apply to legend drugs.
5. (5) Personal comfort or convenience items, including, but not limited to, television, radio, or telephone rental.
6. (6) Services for the remediation of learning disabilities.
7. (7) Treatments or therapies of an educational nature.

8. (8) Experimental radiological or surgical or other modalities and procedures, including, but not limited to, the following:

   1. (A) Acupuncture.
   2. (B) Biofeedback therapy.
   3. (C) Carbon dioxide five percent (5%) inhalator therapy for inner ear disease.
   4. (D) Hyperthermia.
   5. (E) Hypnotherapy.
9. (9) Hair transplants.
10. (10) Fallopian tuboplasty (reanastomosis of the fallopian tubes) for infertility or vasovasostomy (reanastomosis of the vas deferens. This procedure is covered only in conjunction with disease.
11. (11) Augmentation mammoplasties for cosmetic purposes.
12. (12) Dermabrasion surgery for acne pitting or marsupialization.
13. (13) Rhinoplasty or bridge repair of the nose in the absence of a significant obstructive breathing problem.

14. (14) Otoplasty for protruding ears unless one (1) of the following applies to the case:

    1. (A) Multifaceted craniofacial abnormalities due to congenital malformation or maldevelopment, for example, Pierre Robin syndrome.
    2. (B) A member has pending or actual employment where protruding ears would interfere with the wearing of required protective devices.
15. (15) Scar removals or tattoo removals by excision or abrasion.
16. (16) Ear lobe reconstruction.

17. (17) Removal of keloids caused from pierced ears unless one (1) of the following is present:

    1. (A) Keloids are larger than three (3) centimeters.
    2. (B) Obstruction of the ear canal is fifty percent (50%) or more.
18. (18) Rhytidectomy.
19. (19) Penile implants.
20. (20) Perineoplasty for sexual dysfunction.
21. (21) Reconstructive or plastic surgery unless related to disease or trauma deformity.
22. (22) Sliding mandibular osteotomies unless related to prognathism or micrognathism.
23. (23) Blepharoplasties when not related to a significant obstructive vision problem.
24. (24) Radial keratotomy.

25. (25) Miscellaneous procedures or modalities, including, but not limited to, the following:

    1. (A) Autopsy.
    2. (B) Cryosurgery for chloasma.
    3. (C) Conray dye injection supervision.
    4. (D) Day care or partial day care or partial hospitalization except when provided pursuant to 405 IAC 5-20.

    5. (E) Formalized and predesigned rehabilitation programs, including, but not limited to, the following:

       1. (i) Pulmonary.
       2. (ii) Cardiovascular.
       3. (iii) Work-hardening or strengthening.
    6. (F) Telephone transmitter used for transtelephonic monitor.
    7. (G) Telephone, or any other means of communication, consultation from one (1) doctor to another.
    8. (H) Artificial insemination.
    9. (I) Cognitive rehabilitation, except for treatment of traumatic brain injury.
26. (26) Ear piercing.
27. (27) Cybex evaluation or testing or treatment.
28. (28) High colonic irrigation.
29. (29) Services that are not prior authorized under the level-of-care methodology as required by 405 IAC 5-21.5.
30. (30) Amphetamines when prescribed for weight control or treatment of obesity.
31. (31) Under federal law, drug efficacy study implementation drugs not covered by Medicaid.
32. (32) All anorectics, except amphetamines, both legend and nonlegend.
33. (33) Physician samples.

(Office of the Secretary of Family and Social Services; 405 IAC 5-29-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3356, filed Sep 27, 1999, 8:55 a.m.: 23 IR 320; filed Sep 1, 2000, 2:16 p.m.: 24 IR 15; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Oct 3, 2001, 9:47 a.m.: 25 IR 380; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed May 27, 2010, 9:15 a.m.: 20100623-IR-405100045FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; readopted filed Jul 28, 2022, 2:21 p.m.: 20220824-IR-405220205RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)