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UNOFFICIAL 1722-19 [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)

§17-1722-66 Excluded services. The department will not be responsible to pay for the following medical services or conditions: (1) Custodial or domiciliary care; (2) Charges for care in intermediate care or skilled nursing facilities or intermediate care facilities for the mentally retarded; (3) Personal or comfort items as television, telephone, guest trays, or a private room in a hospital unless deemed medically necessary by the treating physician; (4) Emergency facility services for non- emergency conditions; (5) Medical, surgical or other health care procedures, services, drugs or devices that are considered experimental or investigational; (6) Transplant and open heart surgery procedures and coverage of organ donor services; (7) Prescription and non-prescription drugs and hormones and their administration, except those provided as an inpatient hospital service; (8) Sex change operations, investigation of and 0treatment for infertility, reversal of sterilization, artificial insemination, in vitro fertilization, and contraceptive supplies and devices; (9) Vision care services to include eyeglasses, contact lenses, routine eye examinations,

including eye refraction, except as provided as part of routine health assessments; (10) Hearing aids, prosthesis, orthopedic shoes, routine foot care; (11) Purchase or rental of hearing aids or durable medical equipment, including, but not limited to hospital beds, wheel chairs, walk-aids, or other medical equipment not specifically listed as a covered service, except as used while in the hospital; (12) Dental services for temporomandilar joint problems, except for repair necessitated by accidental injury to sound natural teeth or