.04 Covered Services.

A. The Program covers medically necessary services described in §B of this regulation, rendered to participants in a free-standing dialysis facility, when these services are:

(1) Performed by a physician or by one of the following:

(a) A physician assistant;

(b) A nurse practitioner;

(c) An RN;

(d) An LPN;

(e) A social worker; or

(f) A dietitian-nutritionist;

(2) Provided by a non-physician listed in §A(1) of this regulation, when the following conditions are met:

(a) The individual performing the service is in the employ of, or under contract with, the free-standing dialysis facility;

(b) The individual performing the service is under a physician's direct supervision or written direction;

(c) The individual performs the service within the scope of the individual's license or certification for the purpose of assisting in the provision of the physician's services; and

(d) The services are provided according to the free-standing dialysis facility physician's written plan of care;

(3) Curative or rehabilitative services, when clearly related to the participantís individual needs;

(4) Adequately described in the participantís medical record and consistent with the physicianís written plan of care.

B. Covered services include:

(1) Dialysis services furnished on an outpatient basis and provided by a free-standing dialysis facility, to include hemodialysis, peritoneal dialysis, CAPD, CCPD, and home dialysis training; and

(2) Laboratory tests, supplies, and prescription drugs as related to dialysis services.