South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:08 - Services not covered

Current through Register Vol. 51, page 10, July 15, 2024
In addition to items and services specified as not covered in other
	 sections of this article, the following items and services are not covered
	 under the medical assistance program:
(1) Items or services which have been
  determined by the state dental or medical consultant or through peer reviews to
  be not medically necessary, safe, or effective;
(2) Items or services for which the recipient
  has no legal obligation to pay or which are charges imposed by immediate
  relatives or members of the recipient's household;
(3) Over-the-counter drugs, home remedies,
  food supplements, nutritional items, vitamins, or alcoholic beverages, except
  as covered under chapter 67:16:14 or 67:16:42;
(4) Diagnosis or treatment given in the
  absence of the patient;
(5)
  Cosmetic surgery to improve the appearance of an individual, if not incidental
  to prompt repair following an accidental injury or any cosmetic surgery that
  goes beyond that which is necessary to improve the functioning of a malformed
  body member;
(6) Items or services
  provided by practitioners or agencies in the employ of or under contract with
  the federal, state, or local government, except state institutions for the
  developmentally disabled that are certified as skilled nursing or intermediate
  care facilities, the state psychiatric hospital, the public health service, or
  the national health service;
(7)
  Organ transplants, except as authorized under chapter 67:16:31;
(8) Acupuncture;
(9) Biofeedback;
(10) Chronic pain rehabilitation program
  services or chronic pain management services, except as allowed under chapter
  67:16:14;
(11) Alcohol and drug
  rehabilitation therapy, except for services provided under chapter
  67:16:48;
(12) Procedures for
  implanting an embryo;
(13) Gastric
  bypass, gastric stapling, gastroplasty, any similar surgical procedure, or the
  associated conservative weight loss management unless prior
  authorized;
(14) Self-help devices,
  exercise equipment, protective outerwear, personal comfort services or
  environmental control equipment, such as air conditioners, humidifiers,
  dehumidifiers, heaters, or furnaces;
(15) Medical equipment for a resident in a
  health care facility, except as authorized under chapter 67:44:03;
(16) Autopsies;
(17) Custodial care, except as authorized
  under chapter 67:44:03;
(18)
  Nursing facility services for individuals age 21 and over and under age 65 in
  institutions for mental disease;
(19) Broken appointments;
(20) Reports required solely for insurance or
  legal purposes unless requested by the department, the Department of Health, or
  the Department of Human Services;
(21) Concurrent care by more than one
  provider of the same discipline for the same diagnosis without a medical
  referral detailing the medical necessity of the concurrent care. For concurrent
  care without medical referral, the department will pay only the first claim
  submitted;
(22) A health service
  that is not documented in the recipient's medical record as required by chapter
  67:16:34;
(23) Vocational training,
  educational activities, teaching, or counseling, except outpatient diabetes
  self-management education programs covered under chapter 67:16:46;
(24) Record keeping, charting, or
  documentation related to providing a covered service, unless specifically
  allowed in this article;
(25)
  Payment of mileage unless specifically covered under this article;
(26) Drugs and biologicals, which the federal
  government has determined to be less than effective, as listed in §
									67:16:14:05;
(27) Services, procedures, or drugs, which
  are considered experimental by the United States Department of Health and Human
  Services or another federal agency. However, services, procedures, or drugs
  that are approved for emergency use authorization are not considered
  experimental;
(28) Procedures and
  services to reverse sterilization;
(29) Computers, computer hookups, or computer
  printers, unless prior authorized;
(30) Gambling addiction services or therapy;
  and
(31) Penile implants.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Covered services must be medically necessary, §
											67:16:01:06.02.