CMS Pub. 100-11, ch. 6, § 70

The services that are excluded from coverage under the PACE program are as follows:

• Any service that is not authorized by the IDT, even if it is listed as a required

service, unless it is an emergency service;

• Services rendered in a non-emergency setting or for a non-emergency reason

without authorization;

• Prescription and over-the-counter drugs not prescribed by the PACE provider

physician;

• For services in inpatient facilities, private room and private duty nursing services,

(unless medically necessary) and non-medical items for personal convenience

such as telephone charges, radio or television rental, (unless specifically

authorized by the IDT as part of a participant’s plan of care);

• Cosmetic surgery, which does not include surgery required for improved

functioning of a malformed part of the body resulting from an accidental injury or

for reconstruction following mastectomy;

• Experimental medical, surgical or other health procedures.

PACE will not cover services rendered outside the United States, except as may be

permitted in accordance with 42 CFR § 424.122 regarding conditions for payment for

emergency inpatient hospital services and 42 CFR § 424.124 regarding conditions for

payment for physician services and ambulance services or as may be permitted under the

State’s approved Medicaid Plan. There are limited exceptions to this rule. For example, a

State that borders another country might include some Medicaid coverage across the

border, and Medicare covers some emergency hospital, ambulance, and physician

services outside the United States. (As defined in 42 CFR § 400.200, the United States

includes the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa,

and the Northern Mariana Islands).

[42 CFR § 460.96; 71 FR 71282 (Dec. 8, 2006)]