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(6) has received prior authorization from the department, if prior authorization is required under 7 AAC 105 — 7 AAC 160; and
(7) is not specifically excluded as a noncovered service under 7 AAC 105 — 7 AAC 160. (Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199) Statutory Authority: Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.110. Noncovered services. Unless otherwise provided in 7 AAC 105 — 7 AAC 160, the department will not pay for a service that is
(1) not reasonably necessary for the diagnosis and treatment of an illness or injury, or for the correction of an organic system, as determined upon review by the department, or that is not identified in a screening required under 7 AAC 110.205;
(2) not properly prescribed or medically necessary in accordance with criteria established under 7 AAC 105 — 7 AAC 160 or by standards of practice applicable to the prescribing provider;
(3) incurred for an evaluative or periodic checkup, examination, or immunization
(A) that is in connection with the participation, enrollment, attendance, or accomplishment of a program or activity unrelated to the recipient’s physical or mental health or rehabilitation; or
(B) unless it is
(i)an adult preventive service covered under 7 AAC 110.800;#
(i) an adult preventive service covered under 7 AAC 110.800;
(ii)part of an EPSDT screening; or#
(ii) part of an EPSDT screening; or
(iii) required by the department for the purpose of determining eligibility for Medicaid;
(4) for or in connection with cosmetic therapy or plastic or cosmetic surgery, including rhinoplasty, nasal reconstruction, excision of keloids, augmentation mammoplasty, silicone or silastic implants, facioplasty, osteoplasty (prognathism and micronathism), dermabrasion, skin grafts, and lipectomy; however, coverage is available if required for the following corrective