Section 14. Noncovered Services

A. The following services are not the responsibility of the provider or medicaid: (1) any medicaid capitated or fee-for-service benefit which has not been authorized by the multidisciplinary team; (2) in inpatient facilities, private room and private duty nursing, unless medically necessary, and non-medical items for personal convenience, such as telephone charges, radio, or television rental; (3) cosmetic surgery unless required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy; (4) experimental medical, surgical or other health procedures or procedures not generally available; (5) care in a government hospital (veterans administration, federal/state hospital) unless authorized; (6) service in any hospital for the treatment of chronic, medically uncomplicated drug dependency or alcoholism; and (7) any services rendered outside of the United States. B. The participant will be financially responsible for any of the above-mentioned services.