California Code of Regulations
Title 22 - Social Security
Division 3 - Health Care Services
Subdivision 1 - California Medical Assistance Program
Chapter 3 - Health Care Services
Article 4 - Scope and Duration of Benefits
Section 51303 - General Provisions

(a) Health care services set forth in this article and in Chapter 5, Article 4 (commencing with Section 54301 of this title), which are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury are covered by the Medi-Cal program, subject to utilization controls, to the extent specified in this Chapter, Chapter 5, and Chapter 11. Such utilization controls shall take into account those diseases, illnesses, or injuries which require preventive health services or treatment to prevent serious deterioration of health. Nothing in this section shall preclude payment for family planning services, or for early, periodic screening, diagnosis and treatment services (EPSDT), provided under the Child Health and Disability Prevention (CHDP) Program. Authorization may only be granted when fully documented medical justification is provided that the services are medically necessary. Services not requiring prior authorization are subject to other utilization controls, as specified in this chapter.

(b) Limitations specified in this article do not apply to Medicare/Medi-Cal program covered services (crossover services).

(c) Except as set forth in (b) above, if the Medi-Cal Program is to pay any portion of a charge for services for which other coverage is available, the limitations and controls specified in this article apply.

(d) Inpatient services in hospitals are covered only when provided on the signed order of the physician, dentist or podiatrist responsible for the care of the patient.

(e) Inpatient services in skilled nursing facilities and intermediate care facilities are covered only when provided on the signed order of the physician responsible for the care of the patient.

(f) Outpatient services are covered subject to the limitations and controls set forth in this chapter.

(g) Experimental services are not covered.

(h) Investigational services are not covered except when it is clearly documented that all of the following apply:

(i) Services and supplies not primarily medical in purpose or which are common household items are not covered.

(j) Services set forth in this article must be provided by providers who meet, where applicable, the standards set forth in Article 3 of this chapter.

(k) Services prescribed or ordered by a provider suspended from participation in the Medi-Cal program shall not be covered by the program while the suspension is in effect, providing that at least 15 days written notice is given to all affected providers.