R414-71-5. Service Coverage and Limitations

  (1) Screening and diagnostic services to determine physical or mental defects.

  (2) Screening services include:

  (a) a comprehensive health and developmental history, including the assessment of physical and mental development;

  (b) dental and oral health screening;

  (c) comprehensive physical examination;physical examination

  (d) vision screening;

  (e) hearing assessment;

  (f) speech and language development;

  (g) appropriate immunizationsimmunizations according to age and health history;

  (h) laboratory testsLaboratory tests , including blood lead level assessment appropriate to age and risk; and

  (i) health educationHealth education , including anticipatory guidance.

  (3) When a screening indicates the need for further evaluation, diagnostic services must be provided.

  (4) Medically necessary services are available for treatment of all physical and mental illnesses or conditions discovered by any screening or diagnostic procedures.

  (5) Additional services include:

  (a) chiropractic services;

  (b) orthodontia;

  (c) occupational therapy;

  (d) physical therapy;

  (e) speech-language services;

  (f) private duty nursing;

  (g) at a minimum, diagnosis and treatment for defects in vision, including eyeglasses;

  (h) at a minimum, dental services for the relief of pain and infections, restoration of teeth, maintenance of dental health, including examinations, cleanings, and fluoride treatments;

  (i) at a minimum, diagnosis and treatment for hearing defects, including hearing aids; and

  (j) additional health care services coverable under Subsection 1905(a) of the Social Security Act and found to be medically necessary to treat, correct, or ameliorate illness and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

  (6) The Department determines whether a service is medically necessary.

  (7) Medically necessary services do not include:

  (a) experimental or investigational treatments;

  (b) reconstructive and cosmetic procedures as noted in Section R414-1-29;

  (c) services for caregivers or for provider convenience; or

  (d) duplicative services.

  (8) The Department may consider the relative cost effectiveness of alternatives as part of the prior authorization process described in Section R414-1-2.