New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 1 - GENERAL PROVISIONS
Section 10:52-1.8 - Non-covered services (inpatient and outpatient)

i. Admission for any condition for which hospitalization is not medically necessary;

ii. Admission primarily for rest cure, custodial care, convalescent care or diet therapy for exogenous obesity;

iii. Admission for illnesses which, according to generally accepted professional standards, are not amenable to favorable modification. However, psychiatric services in a general hospital shall be covered for the purpose of determining that such disorders or illness (such as senility) are not amenable to favorable modification;

iv. Admission for diagnostic procedures which may be done on an out-of-hospital basis including, but not limited to, laboratory tests, electrocardiograms and diagnostic radiological services;

v. Admission or extension of hospital stay solely for research or teaching studies;

vi. Admission for inpatient services provided in an approved private psychiatric hospital unless:

vii. Admission of beneficiaries in the Medically Needy Program, except for pregnant women. For information on how to identify a Medically Needy beneficiary, see 10:49-2.3(c), Administration.

i. Any service or item which is not medically necessary for the prevention, diagnosis, palliation, rehabilitation or treatment of a disease, injury or condition;

ii. Inpatient hospital services rendered prior to the day it is medically necessary for the diagnostic services or surgical or medical treatment for which the patient is admitted.

iii. Inpatient hospital services rendered in a general hospital at any time following the day that such services are no longer medically necessary, except when special circumstances, that is, "social necessity," exist which prevent the discharge or transfer of the patient or when an inpatient is eligible for "administrative days" (see 10:52-1.14, Social Necessity and 10:52-1.9, Administrative Days).

iv. Inpatient hospital services denied for lack of medical necessity shall not be covered.

i. Cosmetic Surgery, except that the Division shall consider authorization of a request from the patient's physician for elective cosmetic surgery, if a significant redeeming medical necessity can be demonstrated; and,

ii. Second Opinion Elective Procedures without meeting the Second Opinion requirement (see 10:52-1.13 Second Opinion Program);

i. Inpatient items and services including guest meals and accommodations, television, telephone, and similar items and services. Personal items shall be billed to the patient directly, provided the patient is informed and agrees to accept responsibility for personal items; and,

ii. Outpatient items and services which are not usually part of the outpatient service; for example, eyeglasses, custom-made limbs and braces, or surgical supplies.