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Appendix F
General Exclusions
This table presents a sampling of general exclusions, beginning with a set of what was presented as typical
of industry-wide practices,1 followed by a Federal Employees Health Benefits (FEHB) program fee-for-service
product,2 and then exclusions among CIGNA typical small group employer plan,3 UnitedHealthcare small group
plans,4 Wellpoint Anthem Blue Standard small business plan5 (see Appendix E for more detail on the latter), and
the Medicare program.6,7 The FEHB program develops a short list of general exclusions for both its fee-for-service
and managed care plans (see, for example, Chapter 5, Box 5-2), which individual insurers can expand upon.
1 Personal communication, Charles Bevilacqua, Kaiser Permanente; the list of industry-wide practices are not necessarily specific to Kaiser
but identified across many insurers as typical.
2 These are specific to Blue Cross and Blue Shield (BCBS) fee-for-service benefit plan under the FEHBP program (http://www.fepblue.org/
benefitplans/2011-sbp/bcbs-2011-RI71-005.pdf).
3 Personal communication, Rosemary Lester, CIGNA Product, September 9, 2011.
4 Personal communication, Sam Ho, UnitedHealthcare, September 13, 2011.
5 Personal communication, Ruth Raskas, WellPoint, September 9, 2011.
6 CMS (Centers for Medicare and Medicaid Services) Medicare benefit policy manual: Chapter 16—general exclusions from coverage (http://
www.cms.gov/manuals/Downloads/bp102c16.pdf).
7 Responses were compiled exactly as submitted, explaining any variance in style ( e.g., X = excluded; X for Cigna = explicitly excluded or
otherwise not a covered benefit; Y = excluded; N = not excluded).
209
OCR for page 210
TABLE F-1 General Exclusions of Health Plans
210
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
General Exclusions
Service, drugs, or supplies you receive while you are not enrolled in this plan X X X Y Not Covered
Services, drugs, or supplies not required according to accepted standards of X X Y Not Covered
medical, dental, or psychiatric practice in the United States
Services, drugs, or supplies billed by Preferred and Member facilities X X N Not addressed
for inpatient care related to specific medical errors and hospital-acquired in contracts
conditions known as never eventsd
Services not specifically/explicitly listed as covered X X Y Not Covered
All services, drugs, or supplies related to the non-covered service are X X Y Not Covered
excluded from coverage, except services we would otherwise cover to treat
complications of the non-covered service
Services, drugs, or supplies not required to prevent, diagnose, or treat a X X Y Not Covered
medical condition
Services for conditions that a plan physician determines are not responsive to X X Y Not Covered
therapeutic treatment
Services or supplies for which no charge would be made if the covered X X Y Not Covered
individual had no health insurance coverage
Services related to and required as a result of services which are not covered N Not addressed Y
under Medicare in contracts
Medical Necessity Not Coverede
Services deemed not medically necessary X Y
Services, drugs, or supplies that are not medically necessary X X Y
Services not reasonable and necessary X N, eligible Y
expense
Abortion
f
Services, drugs, or supplies related to abortions, except when the life of the X Y Varies across
mother would be endangered if the fetus were carried to term, or when the plans
pregnancy is the result of an act of rape or incest
Active Military Service
Services, drugs, or supplies you receive without charge while in active military X X Y Not Covered
service
OCR for page 211
TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Automobile, No Fault, Any Liability Insurance or Workers’ Compensation Not Covered
by most planse
Care for any condition or injury recognized or allowed as a compensable loss X X Y
through any Workers’ Compensation, occupational disease or similar lawg
Services reimbursable under automobile, no fault, any liability insurance X Nh Y
workers’ compensation
Blood
The cost of whole red blood or red blood cells when they are donated or X Y Not Covered
replaced or billedi by some plans
Charges for Administrative Services
Exclude services, supplies, or devices if they are not prescribed, performed, or X Y Not Covered
directed by a provider or facility not defined by us as such, or not licensed to
do so
Clinical Trials
Research costs (costs related to conducting a clinical trial such as research X Not a Y Not Covered
physician and nurse time, analysis of results, and clinical tests performed only Benefit
for research purposes) unless
mandated
Extra care costs related to taking part in a clinical trial such as additional Not a Y Not Covered
tests that a patient might may need as part of the trial, but not as part of the Benefit
patient’s routine care unless
mandated
Cosmetic Services Not Coverede
Cosmetic servicesj X X Y
Services, drugs, or supplies you receive for cosmetic purposes X X Y
Cosmetic surgery or other procedures performed solely for beautification or to X Y
improve appearance
Surgical treatments of gynecomastia (male breast reduction) for cosmetic X Y
purposes
Cosmetic surgery X Y Y
Counseling
Religious, personal growth counseling or marriage counseling including X X Y, except Not Covered
services and treatment related to religious, personal growth counseling or DSM by most plans
marriage counseling, unless the primary patient has a DSM IV diagnosis diagnosis
also Excluded
211
continued
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TABLE F-1 Continued
212
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Crime
Treatment of injuries sustained while committing a crime X (X in Y Not Covered
plans for by most plans
individuals)
Custodial Care Not Coverede
Custodial care X X Y Y
Custodial care (such as feeding, dressing, bathing, transferring, and activities X Y
of daily living)k
Custodial care means assistance with activities of daily living (e.g., walking, X X Y
getting in and out of bed, bathing, dressing, feeding, toileting, and taking
medicine), or care that can be performed safely and effectively by people who,
in order to provide the care, do not require medical licenses or certificates or
the presence of a supervising licensed nursel
Dental/Oral Services Dental services
Not Covered
with some
variation
across plans
for surgical
extraction of
impacted teeth
and for TMJ
treatment and
appliancese
Any dental or oral surgical procedures or drugs involving orthodontic care, X X Y
the teeth, dental implants, periodontal disease, or preparing the mouth for the
fitting or continued use of denturesm
Orthodontic care for malposition of the bones of the jaw or for X X Y
temporomandibular joint (TMJ) syndrome
Dental procedures and appliances to correct disorders of the X X Y, except
temporomandibular (jaw) joint (also known as TMD or TMJ disorders) surgery is
covered
Routine dental services, including topical and oral fluoride preparations, from X Y
standard medical and pharmacy benefits except where mandated (does not
apply to products with embedded dental coverage)n
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TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Teeth extractions, surgical removal of impacted teeth, and other oral surgical X Y
services (not to include pharmacy services) for care of the teeth or of the
bones and gums directly supporting the teeth. These services are dental and
nature and not covered under medicalo
Extractions, treatment of cavities, care of the gums or structures directly X X Y
supporting the teethp,q
Treatment of periodontal abscess, removal of impacted teeth, orthodontia X X Y
(including braces), false teeth, or any other dental services or supplies, except
as otherwise covered under the plan
Items and services in connection with the care, treatment, filling, removal, or X Y Y
replacement of teeth, or structures supporting the teethr
Any dental procedures involving orthodontic care, inlays, gold or platinum X Y
fillings, bridges, crowns, pin/post reduction, dental implants, surgical
periodontal procedures, or the preparation of the mouth for the fitting or
continued use of dentures
Educational Services; Self-Training; Vocational Services Not Coverede
Self-care or self-help training X Not a Benefit Y
unless
mandated
Educational services, self management/help training services, and vocational Not a Benefit Y
services except where mandated for diabetes and asthma, or where explicitly unless
covered by another benefit mandated
Any educational services and programs or therapies for behavioral/conduct Not a Benefit Y
problemss unless
mandated
Coverage does not include services other than self management of a medical X Not a Benefit Y
condition as determined by the Health Plan to be primarily educational in unless
nature mandated
Equipment
Equipment that basically serves comfort or convenience functions or is X X Y Not Covered
primarily for the convenience of a person caring for you or your dependent,
i.e., exercycle or other physical fitness equipment, elevators, hoyer lifts,
shower/bath bench. Air conditioners, air purifiers and filters, batteries and
charges, dehumidifiers, humidifiers, air cleaners and dust collection devices
213
continued
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TABLE F-1 Continued
214
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Experimental/Investigational Procedures Not Coverede
Experimental or investigational servicest X X Y
Experimental or investigational procedures, treatments, drugs, or devices X X Y
Services related to complications resulting or arising from excluded services X N
except where mandated or where DOI agreements have been made to cover
Services deemed to be experimental or investigational unless specifically X Y
covered (e.g., Clinical Cancer Trials)
Fees Not Coverede
Expenses in excess of usual, customary and reasonable fees X X N, eligible
expense
Free care (no charge items) X X Y
Food and Dietary Supplements
Benefits for food or food supplements, except formulas and/or food products Not a Benefit Y Not Covered
that are prescribed, ordered or supervised by a physician and medically unless
necessary as defined by medical policy mandated
Nutritional supplements and formulae needed for the treatment of inborn X Not a Benefit Y Coveredu
errors of metabolism unless
mandated
Foot Care
Foot carev X N See below Y
Routine or palliative foot care (comfort or cosmetic) unless medically X Y Not Covered
necessary
Shoe inserts, orthotics (except for care of the diabetic foot), and orthopedic X X N, we Not Covered
shoes (except when an orthopedic shoe is joined to a brace) cover one by most plans
pair foot
orthotics
Furniture
Furniture (other than medically necessary durable medical equipment) such as X X Y Not Covered
commercial beds, mattresses, chairs
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TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Government Programs Xe Not Covered
by most plans
except as
required by
mandatee
Treatment where payment is made by any local, state, or federal government X X N
(except Medicaid), or for which payment would be made if the Participant had
applied for such benefits. Services that can be provided through a government
program for which you as a member of the community are eligible for
participation. Such programs include, but are not limited to, school speech and
reading programs
Items and services furnished, paid for or authorized by governmental X N Y
entities—Federal, state, or local governments
Health Club Memberships Xe Not Covered
by most planse
Health club memberships from core medical benefit X Y
Membership costs or fees associated with health clubs, weight loss programs X X Y
Hearing Aids and Routine Hearing Tests Generally Not
Covered by
plans unless
mandatede
Hearing aidsw X Y
Hearing aids, hearing devices and related examinations and services X X Y
Hearing aids and auditory implants Y Y
Hypnotherapy
Hypnotherapy (hypnosis) X X Y Not Covered
Infertility Services
See Reproductive Services See
Reproductive
Services
Legal Liability Not Coverede
Charges which the enrollee or Plan has no legal obligation to pay, such X X Y
as excess charges for an annuitant age 65 or older who is not covered by
Medicare Parts A and/or B, doctor's charges exceeding the amount specified
by the HHS when benefits are payable under Medicare, or State premium
taxes however applied
215
continued
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TABLE F-1 Continued
216
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Services for which the member has no liability to pay in the absence of this X Y
plan’s coverage. This includes, but is not limited to: government programs;
incarceration; workers compensation; and free clinics
No legal obligation to pay for or provide services X N Y
Location Coverede,u
Services, other than Emergency Services, received outside the United States X X Y
whether or not the services are available in the United States
Services not provided within the United States Y Y
Massage Therapy
Massage therapyx X X Y Not Covered
by most plans
Medical Reports
Completion of specific medical reports, including those not directly related X X Y Not Covered
to treatment of the Participant, e.g., employment or insurance physicals, and
reports prepared in connection with litigation
Medical Supplies Criteria for
coverage varies
across planse
Disposable supplies for home use X X Y
Obesity/Weight Loss Services
Services, drugs, or supplies for the treatment of obesity, weight reduction, or X X Y Generally Not
dietary control, except for office visits and diagnostic tests for the treatment Covered by
of morbid obesityy; gastric restrictive procedures, gastric malabsorptive plans unless
procedures, and combination restrictive and malabsorptive procedures mandated
Nutritional counseling when billed by a covered provider such as a physician, X X Y Coveredu as part
nurse, nurse practitioner, licensed certified nurse, nurse practitioner, licensed of Preventative
certified nurse midwife, dietician or nutritionist, who bills independently for services for non-
nutritional counseling services grandfathered
plans after
9/23/2010 if
services are
rendered by
a covered
provider.
Otherwise, Not
Covered for
most plans
OCR for page 217
TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Commercial weight loss programs from core medical benefit X Y Not Covered
Weight reduction programs: fees and charges relating to fitness programs, X X Y Not Covered
weight loss, or weight control programs
Gastric bypass and bariatric surgery except where mandated Not a Y Generally Not
Benefit Covered by
unless plans unless
Mandated mandated
Outpatient Prescription Drugsz
Compounded products unless the drug is listed on our drug formulary or one X X Y Compound
of the ingredients requires a prescription by law Coveredu
only if one of
ingredients
requires a
prescription
Drugs prescribed for cosmetic purposes X X Y Not Covered
Drugs that shorten the duration of the common cold X N Coveredu if a
prescription is
required
Drugs used to enhance athletic performance X X Y Not Covered
Drugs which are available over the counter and prescriptions for which drug X X Y Not Covered
strength may be realized by the over the counter product by most plans
Experimental or investigational drugs X X Y Not Covered
If a service is not covered, any drugs or supplies needed in connection with X X Y Not Covered
that service are not covered
Prescription drugs for which there is an over the counter drug equivalent X X Y Not Covered
Replacement of lost, damaged or stolen drugs X X N Not Covered
by most plans
Special packaging (packaging of prescription medications may be limited to X N Not applicable
standard packaging)
Drugs and supplies needed solely for travel X X N Not Covered
by most plans
Personal Care Items Not Coverede
Personal comfort items X Y Y
Personal comfort items such as beauty and barber services, radio, television, X X Y
or telephone
217
continued
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TABLE F-1 Continued
218
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Personal comfort items such as those that are furnished primarily for your X X Y
personal comfort or convenience, including those services and supplies not
directly related to medical care, such as guest’s meals and accommodations,
hospital admission kit, barber services, telephone charges, radio and television
rentals, homemaker services, travel expenses, over the counter convenience
items and take-home supplies
Providers/Facilities
Services, drugs, or supplies you receive from a provider or facility barred or X Y Not applicable
suspended from the FEHB Program
Services or supplies furnished by immediate relatives or household members, X X Y Not Covered
such as spouse, parents, children, brothers or sisters by blood, marriage or by most plans
adoption
Services (applies to medical and pharmacy services) performed by a provider X Y Not Covered
who is a family member by birth, marriage, or adoption, or by the provider by most plans
to self
Services rendered by a provider who is a close relative or member of your X X Y Not Covered
household. Close relative means wife or husband, parent, child, brother or by most plans
sister, by blood, marriage or adoption
Charges imposed by immediate relatives of the patient or members of the X Y Not Covered Y
patient’s households by most plans
Services or supplies furnished or billed by a noncovered facility, except that X Y, except Not Covered
medically necessary prescription drugs; oxygen; and physical, speech and speech and
occupational therapy rendered by a qualified professional therapist on an occupational
outpatient basis are covered subject to plan limits therapy
Excluded in
most cases
Services, drugs, or supplies you receive from noncovered providers except in X Y, except Not Covered
medically underserved areasaa we do not
allow in
underserved
areas either
Services you receive from a provider that are outside the scope of the X X Y Not Covered
provider's licensure or certification
Services/service charges of standby physicians X X Y Not Covered
by some plans
Care by non-plan providers except for authorized referrals or emergenciesbb Y Not Covered
under certain
plan types
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TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Care by non-plan providers except for authorized referrals, emergencies and X Y Not Covered
out of area urgent care under certain
plan types
Private duty nursing X Y Not Covered
by some plans
Private duty nursing provided in an inpatient setting (acute care or skilled X Y Not Covered
nursing facility)cc by some plans
Private duty nursing as a registered bed patient unless a plan physician X X Y Not Covered
determines medical necessity by some plans
Private duty nursing in home or long term facility X X Y Not Covered
by some plans
Services, supplies, or devices if they are not prescribed, performed, or directed X Y Not Covered
by a provider or facility not defined by us as such, or not licensed to do so
Inpatient hospital or SNF services not delivered directly or under arrangement N Not addressed Y
by the provider in contracts
Care in halfway house X Y Not Covered
Private room unless medically necessary or if a semi-private room is not X X Y Generally Not
available Covered
Recreational Therapy/Activities Not Coverede
Recreational or educational therapy and any related diagnostic testing, except X X Y
as provided by a hospital during a covered inpatient stay
Recreational, diversional and play activities X X Y
Reproductive Services
Fetal reduction surgery X Y Generally not
addressed in
contracts
The reversal of voluntary/elective sterilization X X Y Not Covered
Infertility services when the infertility is caused by or related to voluntary X X Y Not Covered
sterilization by most plans
except as
required by
mandate
219
continued
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TABLE F-1 Continued
220
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
All assisted reproductive technologies (ART) and the associated diagnostic X Y Not Covered
testing and Rx treatments to support ART (e.g., artificial insemination, in-vitro by most plans
fertilization, ZIFT [zygote intrafallopian transfer], GIFT [gamete intrafallopian except as
transfer]) required by
mandate
In vitro fertilization services X Y Not Covered
by most plans
except as
required by
mandate
Infertility services related to advanced reproductive technologies including X X Y Not Covered
but not limited to in vitro fertilization (IVF); gamete intrafallopian transfer by most plans
(GIFT); zygote intrafallopian transfer (ZIFT) and variations of these except as
procedures required by
mandate
Donor charges and services X X Y Not Covered
by most plans
except as
required by
mandate
Cryopreservation of donor sperm and eggs X X Y Not Covered
by most plans
except as
required by
mandate
Any experimental, investigational or unproven infertility procedures or X X Y Not Covered
therapies
Routine Services Not Covered
under some
grandfathered
planse
Routine services and appliances Unable to N Y
determine
definition
of category,
therefore no
comment
OCR for page 221
TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Routine services, such as periodic physical examinations; screening X N
examinations; immunizations; and services or tests not related to a specific
diagnosis, illness, injury, set of symptoms, or maternity caredd
Sexual Transformations/Dysfunction/Inadequacy
Sexual reassignment surgery X X Y Not Covered
Services related to sexual transformations X Y Not Covered
Services, drugs, or supplies related to sex transformations X Y Not Covered
Services, drugs, or supplies related to sex transformations, sexual dysfunction, X X Y See above and
or sexual inadequacy (except for surgical placement of penile prostheses to below
treat erectile dysfunction)
Drugs and devices used for the treatment of sexual dysfunction X Y Not Covered
by some plans
Shift Differentials
Professional charges for shift differentials X X Y Not addressed
in contract
Smoking Cessation
Smoking cessation programs X Y, Programs not
affiliated with
WellPoint
Not Covered
in most plans
Surrogacy Services
provided to an
individual not
covered under
the plan are
Not Coverede
Surrogate parenting X Y
Services related to surrogacy X Y
Services related to conception, pregnancy or delivery in connection with a X X Y
surrogate arrangement. A surrogate arrangement is one in which a woman
agrees to become pregnant and to surrender the baby to another person or
persons who intend to raise the childee
221
continued
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TABLE F-1 Continued
222
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Testing
Testing for ability, aptitude, intelligence or interest X X Y Not Covered
by some plans
Third-party Requests or Requirements
Physical examinations and other services, and related reports and paperwork, X X Y Generally Not
in connection with third-party requests or requirements, such as those for: Covered with
employment, participation in employee programs, insurance, disability, some nuances
licensing, or on court order or for parole or probation across plans
Topical Hyperbaric Oxygen Therapy (THBO)
Topical Hyperbaric Oxygen Therapy (THBO) X Not a N Not addressed
Benefit in contract
Travel or Transportation
Travel or transportation (other than a state licensed professional ambulance X X Y Generally not
service) expenses even though prescribed by a physician, except as noted addressed in
under transplants contract
Treatment of Dementia, Amnesia, or Mental Retardation
Treatment of dementia, amnesia or mental retardation, except for treatment of X Y, no mental Not Covered
psychological symptoms related to these conditions covered by some plans
unless
optional is
purchased
Vein Surgery
Treatments of all varicose and spider vein surgeries for cosmetic purposes X Y Not Covered
Vision Services Vision
services
generally Not
Covered with
some nuances
across planse
Eye glasses and contact lenses for individuals at least 18 years of age. X Y, excluded
any age
Vision correction surgery (e.g., Lasik, radial keratotomy) to correct refractive X Y
error, including near sightedness, far sightedness, and/or astigmatism;
orthoptics and vision therapy/training; prescription and non-prescription
eyewearff
OCR for page 223
TABLE F-1 Continued
Industry FEHB- United
Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare
Radial keratotomy; and surgery, services, evaluations or supplies for the X X Y
surgical correction of near sightedness and/or astigmatism or any other
correction of vision due to a refractive problem
Orthoptics (a technique of eye exercises designed to correct the visual axes of X X Y
eyes not properly coordinated for binocular vision) or visual training
Vision-medical benefits for low vision aids, eyeglasses, contact lenses for X X Y
prescription or fitting and follow-up care thereof, except that covered expenses
will include the purchase of the first pair of eyeglasses, lenses, frames or
contact lenses that follows cataract surgery or loss of lens due to eye disease
for aphakia or aniridia
War Not Covered
by most planse
Any disease or injury resulting from a war, declared or not, or any military X X Y
duty or any release of nuclear energy. Also excluded are charges for services
directly related to military service provided or available from the Veterans’
Administration or military medical facilities as required by law
Services resulting from war X Y Y
a Approximately 25 percent of customers will accept these exclusions as listed. About 50 percent of customers will add exclusions to the list, while the other 25 percent will remove
some exclusions. Those customers who add or remove exclusions typically only make changes to a small number of services. This list of exclusions is typical for both self-funded plans
as well as traditionally insured plans. Self-funded plans, however, tend to customize this list more than fully insured plans.
b This table reflects exclusions for CIGNA’s Typical Small Group Employer Plan.
c This table reflects exclusions for Anthem/Blue Standard Coverage/Typical small group and individual plans.
d Never events are errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such as surgery performed on a wrong body part, and specific
conditions that are acquired during your hospital stay, such as severe bed sores.
e Respondents sometimes answered on the gray category line when specific wording choices did not match their own.
f Elective abortions are not a benefit in the individual plan products; maternity care is not a typical benefit in individual plans.
g Exception: Benefits are provided for actively employed partners and small business owners not covered under a Workers’ Compensation Act or similar law, if elected by the group and
additional premium is paid. Services or supplies for injuries or diseases related to you or your dependent’s job to the extent you or your dependent is required to be covered by a workers’
compensation law.
h Coordination of benefits provided.
i Except expenses for administration and processing of blood and blood products (except blood factors) covered as part of inpatient and outpatient services.
j Except as otherwise specified for services covered under “reconstructive surgery.”
k Does not apply to hospice.
l This exclusion does not apply to services covered under “hospice care.”
m Except as specifically allowable under Oral and maxillofacial surgery.
n Exclusion does not apply to: anesthesia and associated facility charges as a result of age and/or disability criteria; dental accidents—treatment, sought within 12 months, of an injury
to natural teeth and when a treatment plan submitted for prior approval. Injuries resulted from biting and/or chewing are not considered a dental accident; radiation—dental services to
prepare the mouth for radiation therapy to treat head and/or neck cancer.
223
continued
OCR for page 224
TABLE F-1 Continued
224
o Other oral surgical services are covered, including treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; orthognathic surgery that is required because of
a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part; oral/surgical cor -
rection of accident-related injuries; treatment of lesions, removal of tumors and biopsies; incision and drainage of infection of soft tissue not including teeth-related cysts or abscesses.
p Structures supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.
q This exclusion does not apply to accidental injury to sound and natural teeth.
r Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.
s This exclusion does not apply to coverage for medication management.
t A Service is experimental or investigational if the health plan, in consultation with the medical group, determines that: generally accepted medical standards do not recognize it as
safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients); it requires government approval that
has not been obtained when Service is to be provided; it cannot be legally performed or marketed in the United States without FDA approval; it is the subject of a current new drug or
device application on file with the FDA; it is provided as part of a research trial; (see specific section for clinical trials); it is provided pursuant to a written protocol or other document
that lists an evaluation of the service’s safety, toxicity, or efficacy as among its objectives; it is subject to approval or review of an IRB or other body that approves or reviews research; it
is provided pursuant to informed consent documents that describe the services as experimental or investigational, or indicate that the services are being evaluated for their safety, toxicity
or efficacy; or the prevailing opinion among experts is that use of the services should be substantially confined to research settings or further research is necessary to determine the safety,
toxicity, or efficacy of the service.
u Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits,
etc.
v Except when medically necessary.
w Cochlear implants are not necessarily included in the exclusion. Cover routine hearing screenings as a part of preventive care.
x Except when provided as a procedure during a covered therapy.
y A condition in which an individual has a BMI of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment.
z Insurer may outline drugs that should be reviewed based on employer selection: drugs used in the treatment of infertility, sexual dysfunction, weight control, smoking cessation, and
growth hormone.
aa For 2011, for example: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming.
bb A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires
immediate medical or surgical care.
cc Nursing services in a home or hospice setting are covered as a part of home health care benefits and hospice benefits.
dd Certain services are exempted, including those preventive services specifically covered under preventive care (adult and child), preventive screenings specifically listed in the plan
brochure; and certain routine services associated with covered clinical trials.
ee The plan might choose alternative wording for this exclusion: in situations where you receive monetary compensation to act as a surrogate, health plan will seek reimbursement of all
charges for covered services you receive that are associated with conception, pregnancy and/or delivery of the child. A surrogate arrangement is one in which a woman agrees to become
pregnant and to surrender the baby to another person or persons who intend to raise the child.
ff Exclusion does not apply to medial and surgical services for the treatment of injuries and diseases affecting the eye (e.g., eye exams for diabetics, eyewear/contacts and related services
to replace lenses following surgery or injury, etc.).
