67:16:01:08Services not covered.

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 that 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 for which charges are imposed by an immediate relative of the recipient or a member 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 or reconstructive surgery that goes beyond what is necessary to improve the functioning of a malformed body member, excluding: (a) Reconstructive surgery following a medically necessary mastectomy; or (b) Surgery that is incidental to prompt repair following an accidental injury; (6) Items or services provided by a practitioner or agency in the employ of or under contract with the federal, state, or local government, except: (a) State institutions for the developmentally disabled that are certified as skilled nursing or intermediate care facilities; (b) State or local government hospitals or clinics; (c) The United States Public Health Service; or (d) The National Health Service Corps; (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 prescription drugs 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, or 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, 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 twenty-one and over and under age sixty-five in institutions for individuals with a 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) The second and any subsequent claim submitted for 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; (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 training programs covered under chapter 67:16:46; (24) Record keeping, charting, or documentation related to providing a covered service, unless specifically covered in this article; (25) Payment of mileage unless specifically covered under this article; (26) Drugs and biologicals that the federal government has determined to be less than effective according to 42 U.S.C. § 1395y(c) (February 3, 2026); (27) Services, procedures, or drugs that are considered experimental by the United States Department of Health and Human Services or another federal agency, not including services, procedures, or drugs approved by the Food and Drug Administration under an emergency use authorization that are being utilized in accordance with the emergency use authorization; (28) Procedures and services to reverse sterilization; (29) Computers, computer hookups, or computer printers, unless prior authorization has been received from the department pursuant to § 67:16:01:06.03; (30) Gambling addiction services or therapy; and (31) Penile implants.

Source: SL 1975, ch 16, § 1; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 9 SDR 11, effective August 1, 1982; 9 SDR 164, effective June 30, 1983; 10 SDR 79, effective February 1, 1984; 11 SDR 26, effective August 21, 1984; 11 SDR 86, effective December 30, 1984; 15 SDR 204, effective July 6, 1989; 17 SDR 4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 17 SDR 194, effective June 24, 1991; 18 SDR 98, effective December 9, 1991; 19 SDR 26, effective August 23, 1992; 19 SDR 165, effective May 3, 1993; 20 SDR 144, effective March 10, 1994; 22 SDR 32, effective September 11, 1995; 28 SDR 166, effective June 12, 2002; 35 SDR 88, effective October 23, 2008; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5, 2016; 46 SDR 50, effective October 10, 2019; 47 SDR 129, effective June 3, 2021; 53 SDR 35, effective October 1, 2026.