06 EXCLUSIONS

(1) The services and items set out in the TennCare Medicaid Exclusions Rule 1200-13-13-.10(1) and (3)(b) are excluded from coverage by the CoverKids program. (2) In addition to the services and items excluded by Paragraph (1), the following services, products and supplies are also excluded from coverage by the CoverKids program: (a) Audiological therapy or training (b) Beds and bedding equipment as follows: 1. Powered air flotation beds, air fluidized beds (including Clinitron beds), water pressure mattress, or gel mattress 2. Bead beds, or similar devices 3. Bed boards 4. Bedding and bed casings 5. Ortho-prone beds 6. Oscillating beds 7. Springbase beds 8. Vail beds, or similar beds (c) Biofeedback (d) Cushions, pads, and mattresses as follows: 1. Aquamatic K Pads 2. Elbow protectors 3. Heat and massage foam cushion pads 4. Heating pads 5. Heel protectors 6. Lamb’s wool pads 7. Steam packs (e) Diagnostic tests conducted solely for the purpose of evaluating the need for a service which is excluded from coverage under these rules (f) Ear plugs (g) Floor standers, meaning stationary devices not attached to a wheelchair base and not built into the operating system of a power wheelchair that are designed to hold in an upright position an enrollee who uses a wheelchair and who has limited or no ability to stand on his own (h) Food supplements and substitutes including formulas (i) Humidifiers (central or room) and dehumidifiers (j) Medical supplies, over-the-counter, as follows: 1. Alcohol, rubbing 2. Band-aids 3. Cotton balls 4. Eyewash 5. Peroxide 6. Q-tips or cotton swabs (k) Nutritional supplements and vitamins (l) Purchase, repair, or replacement of materials or equipment when the reason for the purchase, repair, or replacement is the result of enrollee abuse (m) Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed except when the following documentation is provided: 1. Explanation of continuing medical necessity for the item, and 2. Explanation that the item was stolen or destroyed, and 3. Copy of police, fire department, or insurance report if applicable (n) Radial keratotomy (o) Reimbursement to a provider or enrollee for the replacement of a rented durable medical equipment (DME), as defined in 1200-13-13-.01, item that is stolen or destroyed (p) Repair of DME items not covered by CoverKids (q) Repair of DME items covered under the provider’s or manufacturer’s warranty (r) Repair of a rented DME item (s) Standing tables Authority: T.C.A. §§ 4-5-202, 4-5-204, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children’s Health Insurance Program State Plan. Administrative History: New rule filed January 11, 2021; effective April 11, 2021.