Adult Medicaid Manual MA-2905- MEDICAID COVERED SERVICES
XLVII. MISCELLANEOUS NON-COVERED ITEMS
REISSUED 08/01/11 – CHANGE NO. 16-11
(XLVII)
E. Paternity testing - contact local child support enforcement office
F. Outpatient cardiac rehabilitation
G. Sterilization under age 21
H. Sterilization reversal
I. Exercise equipment
J. Experimental drugs and procedures
K. Dental crowns if 21 years or older
L. TMJ splints, night guards, and mouthpieces
M. Braces on teeth if 21 years or older
N. Fixed bridgework
O. Dental implants/transplants and treatment involved
P. Precious metals for dental removable appliances and treatment involved
Q. Precision attachments for partials
R. Gold or porcelain restorations
S. DESI drugs - drugs indicated by the FDA to be “less than effective for their prescribed use”
T. Drugs from manufacturers who have not signed a rebate agreement with Medicaid
U. Lift chairs
V. Smoking cessation classes
W. Hypnosis
X. Acupuncture
Y. Breast reconstructive surgery for diagnosis other than breast cancer
Z. Breast reduction under age 19
REVISED 08/01/11 – CHANGE NO. 16-11
(XLVII)
AA. Dental coverage in post partum period for MPW clients
BB. Blood pressure cuffs
CC. Mattress covers, pillow covers, air purifier for allergy sufferers
DD. Vaporizers, humidifiers
EE. Medic alert bracelets
FF. Diaphragms
GG. Fertility treatments
HH. Anti-bedwetting devices
II. Breast pumps
JJ. YMCA or YWCA memberships for pool therapy
KK. Exercise programs at a gym or wellness center
LL. Circumcision - routine newborn
MM. Van conversions for people in wheelchairs
NN. Liposuction
OO. Tummy tuck
PP. Radial Keratotomy
QQ. Lasix Surgery
RR. Visual training
SS. Eye patch
TT. Initial Cochlear ear implant for ages 21 and over
UU. Hearing aids for individuals over age 21
REVISED 08/01/11 – CHANGE NO. 16-11
(XLVII)
VV. Education programs such as Sylvan Learning Center
WW. Ultrasound to determine sex of a child
XX. Medical services provided out of the country
YY. Tattoo removal
ZZ. Payment for copies of medical records
NOTE: relative to all services, products, and procedures specified above and for recipients under the age of 21 in regard to EPSDT requirements, see I. and XXXVII. of this manual section.
