Section 1200-13-13-.10 - [Effective until 2/3/2025] EXCLUSIONS(1) General exclusions. The following items and services shall not be considered covered services by TennCare:(a) Provision of medical assistance which is outside the scope of benefits as defined in these rules.(b) Provision of services to persons who are not enrolled in TennCare, either on the date the services are delivered or retroactively to the date the services are delivered.(c) Services for which there is no Federal Financial Participation (FFP).(d) Services provided outside the United States or its territories.(e) Services provided outside the geographic borders of Tennessee, including transportation to return to Tennessee to receive medical care except in the following circumstances: 1. Emergency medical services are needed because of an emergency medical condition;2. Non-emergency urgent care services are requested because the recipient's health would be endangered if he were required to travel, but only upon the explicit prior authorization of the MCC;3. The covered medical service would not be readily available within Tennessee if the enrollee was physically located in Tennessee at the time of need and the covered service is explicitly prior authorized by the enrollee's TennCare MCC; or4. The out-of-state provider is participating in the enrollee's MCC network.(f) Investigative or experimental services or procedures including, but not limited to:1. Drug or device that lacks FDA approval except when medically necessary as defined by TennCare;2. Drug or device that lacks approval of facility's Institutional Review Board;3. Requested treatment that is the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials; or4. A requested service about which prevailing opinion among experts is that further study is required to determine safety, efficacy, or long-term clinical outcomes of requested service.(g) Services which are delivered in connection with, or required by, an item or service not covered by TennCare, including the transportation to receive such non-covered services, except that treatment of conditions resulting from the provision of non-covered services may be covered if medically necessary, notwithstanding the exclusions set out herein.(h) Items or services furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury.(i) Non-emergency services that are ordered or furnished by an out-of-network provider and that have not been approved by the enrollee's MCC. An exception exists for dually eligible enrollees. In-network care ordered by out-of-network providers is covered for dually eligible enrollees unless the MCO has informed such enrollee in advance of a request for a service that the specific service requires prior authorization and an order from an in-network provider.(j) Services that are free to the public, with the exception of services delivered in the schools pursuant to the Individuals with Disabilities in Education Act (IDEA).(k) Items or services ordered, prescribed, administered, supplied, or provided by an individual or entity that has been excluded from participation in the Medicaid program under the authority of the United States Department of Health and Human Services or the Bureau of TennCare.(l) Items or services ordered, prescribed, administered, supplied, or provided by an individual or entity that is not licensed by the appropriate licensing board.(m) Items or services outside the scope and/or authority of a provider's specialty and/or area of practice.(n) Items or services to the extent that Medicare or a third party payer is legally responsible to pay or would have been legally responsible to pay except for the enrollee's or the treating provider's failure to comply with the requirements for coverage of such services.(o) Medical services for inmates confined in a local, state, or federal prison, jail, or other penal or correctional facility, including a furlough from such facility.(p) Services delivered by a specific provider, even a provider who is an in-network provider with the enrollee's managed care plan, when the managed care plan has offered the enrollee the services of a qualified provider who is available to provide the needed services.(q) Items or services that are not covered by Medicare or a third party payer for an individual enrollee because the item or service is essentially equivalent to a Medicare or third party payer service that is being covered (e.g., home health services for individuals receiving hospice care).(2) Exception to General and Specific Exclusions: COST EFFECTIVE ALTERNATIVE. As approved by CMS and/or authorized by Policy BEN 08-001, each MCC has sole discretionary authority to provide certain cost effective alternatives when providing appropriate medically necessary care. These services are otherwise excluded and are not covered services unless the MCC has followed the procedures set forth in Policy BEN 08-001 and opts at its sole discretion to provide such requested item or service.(3) Specific exclusions. The following services, products, and supplies are specifically excluded from coverage under the TennCare Section 1115 waiver program unless excepted by paragraph (2) herein. Some of these services may be covered under the CHOICES or ECF CHOICES programs or outside the managed care program under a Section 1915(c) Home and Community Based Services waiver when provided as part of an approved plan of care, in accordance with the appropriate approved TennCare Home and Community Based Services waiver.(a) Services, products, and supplies that are specifically excluded from coverage except as medically necessary for children under the age of 21:1. Audiological therapy or training2. Beds and bedding equipment as follows:(i) Powered air flotation beds, air fluidized beds (including Clinitron beds), water pressure mattress, or gel mattress For persons age 21 and older: Not covered unless a member has both severely impaired mobility (i.e., unable to make independent changes in body position to alleviate pain or pressure) and any stage pressure ulcer on the trunk or pelvis combined with at least one of the following: impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory status.(ii) Bead beds, or similar devices(iv) Bedding and bed casings(viii) Vail beds, or similar bed4. Cushions, pads, and mattresses as follows: (iii) Heat and massage foam cushion pads5. Diagnostic tests conducted solely for the purpose of evaluating the need for a service which is excluded from coverage under these rules.7. Food supplements and substitutes including formulas For persons 21 years of age and older: Not covered, except that Parenteral Nutrition formulas, Enteral Nutrition formulas for tube feedings and phenylalanine-free formulas (not foods) used to treat PKU, as required by T.C.A. § 56-7-2505, are covered for adults. In addition, oral liquid nutrition may be covered when medically necessary for adults with swallowing or breathing disorders who are severely underweight (BMIlt;15 kg/m2) and physically incapable of otherwise consuming a sufficient intake of food to meet basic nutritional requirements.8. Hearing services, including the prescribing, fitting, or changing of hearing aids and cochlear implants9. Humidifiers (central or room) and dehumidifiers10. Inpatient rehabilitation facility services11. Medical supplies, over-the-counter, as follows: (vi) Q-tips or cotton swabs12. Nutritional supplements and vitamins, over-the-counter, except that prenatal vitamins for pregnant women and folic acid for women of childbearing age are covered13. Orthodontic services, except as defined in Rule 1200-13-13-.04(1)(b) 5. or 1200-13-14-.04(1)(b)5.14. Certain pharmacy items as follows: (i) Agents when used for anorexia or weight loss(ii) Agents when used to promote fertility(iii) Agents when used for cosmetic purposes or hair growth(iv) Agents when used for the symptomatic relief of cough and colds(v) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee(vi) Nonprescription drugs(vii) Buprenorphine-containing products used for treatment of opiate addiction in excess of the covered amounts listed below:(I) Dosage of sixteen milligrams (16 mg) per day for a period of up to six (6) months (183 days) from the initiation of therapy or from the conclusion of pregnancy, if the enrollee is pregnant during this initial maximum dosage therapy; and(II) Dosage of eight milligrams (8 mg) per day after the sixth (6th) month (183rd day) of therapy.(viii) Sedative hypnotic medications in dosage amounts that exceed the dosage amounts listed below: (I) Fourteen (14) pills per month for sedative hypnotic formulations in pill form such as Ambien and Lunesta;(II) One hundred forty milliliters (140 ml) per month of chloral hydrate; or(III) One (1) bottle every sixty (60) days of Zolpimist.(x) Opioid products are restricted as set out in Rule .04(1)(c)12.15. Purchase, repair, or replacement of materials or equipment when the reason for the purchase, repair, or replacement is the result of enrollee abuse16. Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed except when the following documentation is provided: (i) Explanation of continuing medical necessity for the item, and(ii) Explanation that the item was stolen or destroyed, and(iii) Copy of police, fire department, or insurance report if applicable18. Reimbursement to a provider or enrollee for the replacement of a rented durable medical equipment (DME) item that is stolen or destroyed19. Repair of DME items not covered by TennCare20. Repair of DME items covered under the provider's or manufacturer's warranty21. Repair of a rented DME item22. Speech, language, and hearing services to address speech problems caused by mental, psychoneurotic, or personality disorders24. Vision services for persons 21 years of age and older that are not needed to treat a systemic disease process including, but not limited to: (i) Eyeglasses, sunglasses, and/or contact lenses for persons aged 21 and older, including eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, sunglasses, and/or contact lenses; procedures performed to determine the refractive state of the eye(s); one pair of cataract glasses or lenses is covered for adults following cataract surgery(iv) Vision perception training(b) Services, products, and supplies that are specifically excluded from coverage under the TennCare program.1. Air cleaners, purifiers, or HEPA filters3. Animal therapy including, but not limited to: 6. Bathtub equipment and supplies as follows: 7. Beds and bedding equipment as follows: (i) Adjust-a-Beds, lounge beds, or similar devices9. Body adornment and enhancement services including, but not limited to: (iii) Breast capsulectomy(iv) Breast implant removal that is not medically indicated(vi) Hair transplantation, and agents for hair growth(vii) Tattoos or removal of tattoos(viii) Tongue splitting or repair of tongue splitting10. Breathing equipment as follows: (i) Intrapulmonary Percussive Ventilators (IPVs)(ii) Spirometers, except for peak flow meters for medical management of asthma and incentive spirometers11. Carbon dioxide therapy12. Care facilities or services, the primary purpose of which is non-medical, including, but not limited to:(ii) Evening care centers(iii) Respite care, except as a component of Mental Health Crisis Services benefits or Hospice Care benefits as provided at Rule 1200-13-13-.04(1)(b).(v) Social or diversion services related to the judicial system13. Carotid body tumor, excision of, as treatment for asthma14. Chelation therapy, except for the treatment of heavy metal poisoning or secondary hemochromatosis in selected settings. Chelation therapy for treatment of arteriosclerosis or autism is not covered. Chelation therapy for asymptomatic individuals is not covered. In the case of lead poisoning, the lead levels must be extremely high. For children, a minimum level of 45 ug/dl is recommended. Because chelation therapy and its after-effects must be continuously monitored for possible adverse reactions, chelation therapy is covered only in inpatient or outpatient hospital settings, renal dialysis facilities, and skilled nursing facilities. It is not covered in an office setting, an ambulatory surgical center, or a home setting.15. Clothing, including adaptive clothing17. Comfort and convenience items including, but not limited to: (iii) Incontinence products (diapers/liners/underpads) not needed for a medical condition; not covered for children age 3 and younger, except Infant Diapers as described in Rule .04(iv) Support stockings, when light or medium weight or prescribed for relief of tired or aching legs or treatment of spider/varicose veins. Surgical weight stockings prescribed by a doctor or other qualified licensed health care practitioner for the treatment of chronic foot/ankle swelling, venous insufficiencies, or other medical conditions and thrombo-embolic deterrent support stockings for pre- and post-surgical procedures are covered as medically necessary.18. Computers, personal, and peripherals including, but not limited to printers, modems, monitors, scanners, and software, including their use in conjunction with an Augmentative Communication Device20. Cosmetic dentistry, cosmetic oral surgery, and cosmetic orthodontic services21. Cosmetic prosthetic devices22. Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem, including scar revision. The following services are not considered cosmetic services: (i) Reconstructive surgery to correct the results of an injury or disease(ii) Surgery to treat congenital defects (such as cleft lip and cleft palate) to restore normal bodily function(iii) Surgery to reconstruct a breast after mastectomy that was done to treat a disease, or as a continuation of a staged reconstructive procedure(iv) In accordance with Tennessee law, surgery of the non-diseased breast following mastectomy and reconstruction to create symmetrical appearance(v) Surgery for the improvement of the functioning of a malformed body member(vi) Reduction mammoplasty, when the minimum amount of breast material to be removed is equal to or greater than the 22nd percentile of the Schnur Sliding Scale based on the individual's body surface area.24. Services provided solely or primarily for educational purposes, including, but not limited to: (i) Academic performance testing(ii) Educational tests and training programs(vii) Picture illustrations(viii) Remedial education(ix) Sign language instruction25. Encounter groups or workshops26. Environmental modifications including, but not limited to: (i) Air conditioners, central or unit(ii) Micronaire environmentals, and similar devices(iv) Portable room heaters(v) Vacuum systems for dust filtering27. Exercise equipment including, but not limited to: (ii) Exercycles (including cardiac use)(iii) Functional electrical stimulation(iv) Gravitronic traction devices(v) Gravity guidance inversion boots(viii) Tilt tables when used for inversion28. Food and food products (distinct from food supplements or substitutes, as defined in Rule 1200-13-13-.10(3)(a) 10.), including but not limited to specialty food items for use in diets such as: (i) Low-phenylalanine or phenylalanine-free29. Generators and auxiliary power equipment that may be used to provide power for covered medical equipment or for any purpose30. Grooming services including, but not limited to: 32. Home health aide services or services from any other individual or agency that are for the primary purpose of safety monitoring33. Home modifications and items for use in the home(iii) Environmental accessibility modifications such as grab bars and ramps(v) Furniture, indoor or outdoor(ix) Patios, sidewalks, driveways, and concrete slabs(xiv) Room additions and room expansions(xv) Telephone alert systems(xvii) Telephone service in home(xix) Tilt tables when used for inversion(xx) Toilet trainers and potty chairs. Positioning commodes and toilet supports are covered as medically necessary.(xxi) Utilities (gas, electric, water, etc.)35. Hospital inpatient items that are not directly related to the treatment of an injury or illness (such as radios, TVs, movies, telephones, massage, guest beds, haircuts, hair styling, guest trays, etc.)36. Hotel charges, unless pre-approved in conjunction with a transplant or as part of a non-emergency transportation service37. Hypnosis or hypnotherapy38. Infant/child car seats, except that adaptive car seats may be covered for a person with disabilities such as severe cerebral palsy, spina bifida, muscular dystrophy, and similar disorders who meets all of the following conditions: (i) Cannot sit upright unassisted, and(ii) Infant/child care seats are too small or do not provide adequate support, and(iii) Safe automobile transport is not otherwise possible.39. Infertility or impotence services including, but not limited to: (i) Artificial insemination services(ii) Purchase of donor sperm and any charges for the storage of sperm(iii) Purchase of donor eggs, and any charges associated with care of the donor required for donor egg retrievals or transfers of gestational carriers(iv) Cryopreservation and storage of cryopreserved embryos(v) Services associated with a gestational carrier program (surrogate parenting) for the recipient or the gestational carrier(vii) Home ovulation prediction kits(viii) Services for couples in which one of the partners has had a previous sterilization procedure, with or without reversal(ix) Reversal of sterilization procedures(x) Any other service or procedure intended to create a pregnancy(xi) Testing and/or treatment, including therapy, supplies, and counseling, for frigidity or impotence40. Injections for the treatment of pain such as:(i) Facet/medial branch injections for therapeutic purposes(ii) Medial branch injections for diagnostic purposes in excess of four (4) injections in a calendar year(iii) Trigger point injections in excess of four (4) injections per muscle trigger point during any period of six (6) consecutive months(iv) Epidural steroid injections in excess of three (3) injections during any period of six (6) consecutive months, except epidural injections associated with childbirth42. Lifts as follows: (ii) Electric powered recliner, elevating seats, and lift chairs(iv) Overhead or ceiling lifts, ceiling track system lifts, or wall mounted lifts when installation would require significant structural modification and/or renovation to the dwelling (e.g., moving walls, enlarging passageways, strengthening ceilings and supports). The request for prior authorization must include a specific breakdown of equipment and installation costs, specifying all required structural modifications (however minor) and the cost associated thereto.(v) Stairway lifts, stair glides, and platform lifts, including but not limited to Wheel-O-Vators43. Ligation of mammary arteries, unilateral or bilateral45. Motor vehicle parts and services including, but not limited to: (ii) Automobile repairs or modifications48. Naturopathic services50. Organ and tissue transplants that have been determined experimental or investigational51. Organ and tissue donor services provided in connection with organ or tissue transplants covered pursuant to Rule 1200-13-13-.04(1)(b) 22., including, but not limited to: (i) Transplants from a donor who is a living TennCare enrollee and the transplant is to a non-TennCare enrollee(ii) Donor services other than the direct services related to organ procurement (such as, hospitalization, physician services, anesthesia)(iii) Hotels, meals, or similar items provided outside the hospital setting for the donor(iv) Any costs incurred by the next of kin of the donor(v) Any services provided outside of any "bundled rates" after the donor is discharged from the hospital52. Oxygen, except when provided under the order of a physician and administered under the direction of a physician53. Oxygen, preset system (flow rate not adjustable)54. Certain pharmacy items as follows: DESI, LTE, and IRS drugs57. Prophylactic use of stainless steel crowns59. Psychogenic sexual dysfunction or transformation services61. Recertification of patients in Level 1 and Level II Nursing Facilities64. Retreats for mental disorders66. Routine health services which may be required by an employer; or by a facility where an individual lives, goes to school, or works; or by the enrollee's intent to travel (ii) Employment and pre-employment physicals(iii) Fitness to duty examinations(iv) Immunizations related to travel or work(vi) Job related illness or injury covered by workers' compensation67. Sensitivity training or workshops68. Sensory integration therapy and equipment used in sensory integration therapy including, but not limited to:(x) Weighted blankets or weighted vests69. Sensory stimulation services70. Services provided by immediate relatives, i.e., a spouse, parent, grandparent, stepparent, child, grandchild, brother, sister, half brother, half sister, a spouse's parents or stepparents, or members of the recipient's household71. Sex change or transformation surgery72. Sexual dysfunction or inadequacy services and medicine, including drugs for erectile dysfunctions and penile implant devices74. Speech devices as follows: (i) Phone mirror handivoice(iii) Speech teaching machines75. Sphygmomanometers (blood pressure cuffs)77. Supports: Cervical pillows78. TENS (transcutaneous electrical nerve stimulation) units for the treatment of chronic lower back pain81. Time involved in completing necessary forms, claims, or reports83. Toy equipment such as: Flash switches (for toys)84. Transportation costs as follows: (i) Transportation to a provider who is outside the geographical access standards that the MCC is required to meet when a network provider is available within such geographical access standards or, in the case of Medicare beneficiaries, transportation to Medicare providers who are outside the geographical access standards of the TennCare program when there are Medicare providers available within those standards(ii) Mileage reimbursement, car rental fees, or other reimbursement for use of a private vehicle unless prior authorized by the MCC in lieu of contracted transportation services(iii) Transportation back to Tennessee from vacation or other travel out-of-state in order to access non-emergency covered services (unless authorized by the MCC)(iv) Any non-emergency out-of-state transportation, including airfare, that has not been prior authorized by the MCC. This includes the costs of transportation to obtain out-of-state care that has been authorized by the MCC. Out-of-state transportation must be prior authorized independently of out-of-state care.86. Urine drug testing that, within a calendar year, is in excess of twenty-four (24) presumptive urine drug tests using optical observation, and twelve (12) presumptive urine drug tests using instrument chemistry analyzers, and twelve (12) definitive drug urine tests87. Vagus nerve stimulators, except after conventional therapy has failed in treating partial onset of seizures88. Weight loss or weight gain and physical fitness programs including, but not limited to: (i) Dietary programs of weight loss programs, including, but not limited to, Optifast, Nutrisystem, and other similar programs or exercise programs. Food supplements will not be authorized for use in weight loss programs or for weight gain.(ii) Health clubs, membership fees (e.g., YMCA)(iii) Marathons, activity and entry fees89. Wheelchairs and wheelchair accessories as follows:(i) Wheelchairs defined by CMS as power operated vehicles (POVs), namely, scooters and devices with three (3) or four (4) wheels that have tiller steering and limited seat modification capabilities (i.e. provide little or no back support).(ii) Standing wheelchairs. However a power standing system is covered as set out in the definition of Power Seating Accessories in Rule 1200-13-13-.01.(iii) Stair climbing wheelchairs.(iv) Recreational wheelchairs.90. Whirlpools and whirlpool equipment such as:(i) Action bath hydro massage(iv) Aquasage pump, or similar devices(v) Hand-D-Jets, or similar devices(vi) Jacuzzis, or similar devices(viii) Whirlpool bath equipmentTenn. Comp. R. & Regs. 1200-13-13-.10
Public necessity rule filed July 1, 2002; effective through December 13, 2002. Original rule filed September 30, 2002; to be effective December 14, 2002; however, on December 9, 2002, the House Government Operations Committee of the General Assembly stayed Rule 1200-13-13-.10; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Repeal and new rule filed October 27, 2005; effective January 10, 2006. Public necessity rules filed May 3, 2006; effective through October 15, 2006. Public necessity rule filed May 3, 2006; effective through October 15, 2006. Amendment filed July 28, 2006; effective October 11, 2006. Public necessity rule filed February 2, 2007; effective through July 16, 2007. Amendment filed January 30, 2007; effective April 15, 2007. Amendment filed May 2, 2007; effective July 16, 2007. Amendment filed June 27, 2007; effective Sept 10, 2007. Amendment filed February 8, 2008; effective April 23, 2008. Amendment filed February 11, 2008; effective April 26, 2008. Amendment filed April 2, 2008; effective June 16, 2008. Amendments filed August 19, 2008; effective November 2, 2008. Amendment filed July 28, 2009; effective October 26, 2009. Amendment filed November 9, 2009; effective February 7, 2010. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Amendment filed October 26, 2010; effective January 24, 2011. Amendment filed December 14, 2010; effective May 31, 2011. Emergency rule filed July 1, 2011; effective through December 28, 2011. Emergency rule filed August 2, 2011; effective through January 29, 2012. Amendment filed September 23, 2011; effective December 22, 2011. Amendment filed October 28, 2011; effective January 26, 2012. Emergency rule filed September 27, 2013; effective through March 26, 2014. Amendment filed July 1, 2013; effective September 29, 2013. Amendment filed September 27, 2013; effective December 26, 2013. Amendment filed December 17, 2013; effective March 17, 2014. Amendments filed December 23, 2014; effective March 23, 2015. Emergency rule filed September 30, 2015; effective through March 28, 2016. Amendments filed December 29, 2015; effective March 28, 2016. Amendments filed December 30, 2015; effective March 29, 2016. Emergency rules filed June 24, 2016; effective through December 21, 2016. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 13, 2016; effective December 12, 2016. Amendments filed September 30, 2016; effective December 29, 2016. Amendments filed September 25, 2017; effective December 24, 2017. Emergency rules filed January 16, 2018; effective through July 15, 2018. Amendments filed April 9, 2018; effective July 8, 2018. Amendments filed July 8, 2021; effective October 6, 2021. Amendments filed February 16, 2022; effective May 17, 2022. Emergency rules filed December 27, 2022 to become effective January 1, 2023; effective through June 30, 2023. Amendments filed January 19, 2023; effective 4/19/2023. Emergency rules filed 8/7/2024; exp. through 2/3/2025 (Emergency).Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-102, 71-5-105, 71-5-107, 71-5-109, 71-5-113, and 71-5-134; 42 C.F.R. Part 431 Subpart E; 42 C.F.R. Part 438 Subpart F; Executive Order No. 23; and Public Chapter 473, Acts of 2011.