5160-4-28 Noncovered services.

The following physician services are noncovered:

(A) All services exceeding the policies and limitations defined in Chapter 5101:3-1 a of the Administrative Code.

(B) Services determined by the department as not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(C) Services of a preventive nature except preventive medicine services listed in rule 5101:3-4-34 of the Administrative Code.

(D) Abortions other than those that meet the criteria for coverage set forth in rule 5101:3-17-01 of the Administrative Code.

(E) Infertility services, defined in accordance with rule 5101:3-21-03 of the Administrative Code, including but not limited to artificial insemination, in vitro fertilization, assisted reproductive technologies(ART), and procedures for reversal of voluntary sterilization.

(F) Treatment of obesity, including but not limited to gastroplasty, gastric stapling, ileo-jejunal shunt, or other gastric restrictive procedures.

(J) Plastic or cosmetic surgery performed for aesthetic purposes, including, but not limited to: rhinoplasty, ear piercing, mammary augmentation or reduction, tattoo removal, excision of keloids, fascioplasty, osteoplasty

(prognathism and micrognathism), dermabrasion, skin grafts, lipectomy, and blepharoplasty.

(H) Services related to forensic studies.

(I) Paternity testing.

(J) Acupuncture.

(K) Biofeedback services.

(L) Services determined by another third-party payer or medicare as not medically necessary.

(M) Services of a research nature or services that are experimental and not in accordance with customary standards of medical practice.

(N) Autopsy services.

(O) Special services and reports listed under miscellaneous services in the CPT. "CPT" (current procedural terminology) as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(P) Assisted suicide and other services provided for the specific intent of causing, or assisting to cause death. Assisted suicide does not include withholding or withdrawing of medical treatment, care, nutrition, hydration, or provision of palliative care, even if the service may increase the risk of death, so long as the service is not furnished for the specific purpose of causing death.

(Q) Patient convenience items, including television service.

(R) Pregnancy related services pertaining to a pregnancy that is a result of a contract for surrogacy services. For the purposes of this rule, "surrogacy services" means a woman agrees to become pregnant for the purpose of gestating and giving birth to a child she will not raise, but hand over to a contracted party.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 9/1/89, 4/1/92 (Emer), 7/1/92, 7/1/93, 1/4/00 (Emer), 3/20/00, 12/31/01 (Emer), 3/9/02, 12/30/05 (Emer), 3/27/06, 11/13/06