The following services are excluded from coverage under PACE:

(a) Cosmetic surgery, which does not include surgery that is required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy.

(b) Experimental medical, surgical, or other health procedures.

(c) Services furnished outside of the United States, except as follows:

(1) In accordance with § 424.122 and § 424.124 of this chapter.

(2) As permitted under the State's approved Medicaid plan.