This section includes services, supplies and treatments that are not Covered Health Services, except as may be specifically provided for in What the UnitedHealthcare Medical Plans Cover section of this Book.
The Plan does not pay Benefits for any of the following services, treatments or supplies even if they are recommended or prescribed by a provider or are the only available treatment for your condition.
Also, please review all limits described in the What the UnitedHealthcare Medical Plans Cover section of this Bookcarefully, as the Plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these benefit limits.
Alternative Treatments acupressure; aromatherapy; hypnotism; massage therapy; rolfing;
other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health;
services received by a naturopath; holistic or homeopathic care. Comfort or Convenience
television; telephone;
beauty/barber service; guest service;
supplies, equipment and similar incidental services and supplies for personal comfort. Examples include:
air conditioners; air purifiers and filter;
batteries and battery chargers; dehumidifiers;
humidifiers;
devices and computers to assist in communication and speech;
home remodeling to accommodate a health need (such as, but not limited to, ramps and swimming pools).
Dental
dental care, except as described in What the UnitedHealthcare Medical Plans Cover section of this Book under the heading Dental Services;
preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples include all of the following:
extraction, restoration and replacement of teeth; medical or surgical treatments of dental conditions; services to improve dental clinical outcomes; dental implants;
dental braces;
dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia; however, this exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Plan, as identified in What the UnitedHealthcare Medical Plans Cover section of this Book;
treatment of congenitally missing, malpositioned or super numerary teeth, even if part of a Congenital Anomaly.
Drugs (Refer to the Prescription Plan Section)
prescription drug products for outpatient use that are filled by a prescription order or refill; self-injectable medications;
non-injectable medications given in a Physician's office except as required in an Emergency; over the counter drugs and treatments.
Experimental or Investigational Services or Unproven Services
Experimental or Investigational Services and Unproven Services are excluded. The fact that an Experimental or Investigational Service or an Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular
condition. Foot Care
hygienic and preventive maintenance foot care. Examples include the following: cleaning and soaking the feet;
applying skin creams in order to maintain skin tone;
other services that are performed when there is not a localized illness, Injury or symptom involving the foot;
treatment of flat feet;
treatment of subluxation of the foot. Medical Supplies and Appliances
devices used specifically as safety items or to affect performance in sports-related activities; prescribed or non-prescribed medical supplies and disposable supplies. Examples include:
elastic stockings; ace bandages; gauze and dressings; syringes;
diabetic test strips;
orthotic appliances other than foot orthotics and cranial banding as described under Durable Medical Equipment (DME).
tubings, nasal cannulas, connectors and masks are not covered except when used with Durable Medical Equipment as described in What the UnitedHealthcare Medical Plans Cover section of this Book under the heading Durable Medical Equipment.
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Mental Health/Substance Use Disorder
Exclusions listed directly below apply to services described under Mental Health Services,
Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders and/or Substance Use
Disorder Services in What the UnitedHealthcare Medical Plans Cover section of this Book.
services performed in connection with conditions not classified in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association;
services or supplies for the diagnosis or treatment of Mental Illness, alcoholism or substance use disorders that, in the reasonable judgment of the Mental Health/Substance Use Disorder
Administrator, are any of the following:
not consistent with generally accepted standards of medical practice for the treatment of such conditions;
not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental;
not consistent with the Mental Health/Substance Use Disorder Administrator's level of care guidelines or best practices as modified from time to time; or
not clinically appropriate for the patient's Mental Illness, Substance Use Disorder or condition based on generally accepted standards of medical practice and benchmarks.
Mental Health Services as treatments for V-code conditions as listed within the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric Association;
Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known physical basis;
treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders and paraphilias (sexual behavior that is considered deviant or abnormal);
educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning;
tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act;
learning, motor skills and primary communication disorders as defined in the current edition of the
Diagnostic and Statistical Manual of the American Psychiatric Association;
mental retardation as a primary diagnosis defined in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association;
methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents for drug addiction;
intensive behavioral therapies such as applied behavioral analysis for Autism Spectrum Disorders; and
any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered Experimental or Investigational or Unproven Services.
Nutrition
megavitamin and nutrition based therapy;
nutritional counseling for either individuals or groups including weight loss programs, health clubs and spa programs;
food of any kind. Foods that are not covered include:
enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk, unless they are the only source of nutrition or unless they are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU). Infant formula available over the counter is always excluded;
foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes;
oral vitamins and minerals;
meals you can order from a menu, for an additional charge, during an Inpatient Stay; and other dietary and electrolyte supplements.
Physical Appearance
Cosmetic Procedures. Examples include:
pharmacological regimens, nutritional procedures or treatments;
scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures);
skin abrasion procedures performed as a treatment for acne;
replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered
reconstructive if the initial breast implant followed mastectomy. See Reconstructive Procedures in What the UnitedHealthcare Medical Plans Cover section of this Book;
physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility and diversion or general motivation;
weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded;
wigs regardless of the reason for the hair loss; services received from a personal trainer; liposuction.
Providers
services performed by a provider who is a family member by birth or marriage, including
Spouse/Domestic Partner, brother, sister, parent or child. This includes any service the provider may perform on himself or herself;
services performed by a provider with your same legal residence;
services provided at a free-standing or Hospital-based diagnostic facility without an order written by a Physician or other provider. Services that are self-directed to a free-standing or Hospital- based diagnostic facility. Services ordered by a Physician or other provider who is an employee or representative of a free-standing or Hospital-based diagnostic facility, when that Physician or other provider:
has not been actively involved in your medical care prior to ordering the service; or is not actively involved in your medical care after the service is received.
This exclusion does not apply to mammography testing. Reproduction
health services and associated expenses for infertility treatments; surrogate parenting;
the reversal of voluntary sterilization;
fees or direct payment to a donor for sperm or ovum donations; monthly fees for maintenance and/or storage of frozen embryos; health services and associated expenses for elective abortion; fetal reduction surgery;
health services associated with the use of non-surgical or drug-induced Pregnancy termination. Transplants
health services for organ, multiple organ and tissue transplants, except as described in
Transplantation Services in What the UnitedHealthcare Medical Plans Cover section of this Book, unless UnitedHealthcare determines the transplant to be appropriate according to
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health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs for removal are payable for a transplant through the organ recipient's Benefits under the Plan.);
health services for transplants involving mechanical or animal organs;
transplant services that are not performed at a Designated Facility as defined in the Definitions section of this book;
any multiple organ transplant not listed as a Covered Health Service under the heading Transplantation Health Services in What the UnitedHealthcare Medical Plans Cover section of this Book, unless determined by UnitedHealthcare to be a proven procedure for the involved diagnoses.
Travel
health services provided in a foreign country, unless required as Emergency Health Services; travel or transportation expenses, even though prescribed by a Physician. Some travel expenses
related to covered services rendered at United Resource Networks participating programs or Designated Facilities may be reimbursed at our discretion.
Vision and Hearing
implantable lenses used only to correct a refractive error (such as Intacs corneal implants); purchase cost and associated fitting charges for eyeglasses or contact lenses, except for the first
set of contact lenses and/or eyeglasses needed due to surgery which removes the natural lens; eye exercise or vision therapy other than as a treatment for strabismus (misalignment of the
eyes);
surgery and other related treatment that is intended to correct nearsightedness, farsightedness, presbyopia and astigmatism including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy;
hearing aids or examinations for their prescription or fitting, except for one aid or one pair per lifetime; this is a one-time benefit limited to $1,000 maximum (batteries are not covered); bone anchored hearing aids except when either of the following applies:
for Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or
for Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.
The Plan will not pay for more than one bone anchored hearing aid per Covered Person who meets the above coverage criteria during the entire period of time the Covered Person is enrolled in this Plan. In addition, repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the above coverage are not covered, other than for malfunctions;
All Other Exclusions (this list is not intended to be all-inclusive)
1. health services and supplies that do not meet the definition of a Covered Health Service.
2. physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered under the Plan when:
required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption;
related to judicial or administrative proceedings or orders; conducted for purposes of medical research;
required to obtain or maintain a license of any type;
3. health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. This exclusion does not apply to Covered Persons who are civilians injured or otherwise affected by war, any act of war or terrorism in a non- war zone;
4. charges for any injury, condition, illness or disease incurred as a result of any accident involving an automobile, boat, plane, dirt bike, motorcycle, bicycle, bus, or other vehicle. Benefits may be deemed
eligible once complete accident details are received by the plan and you agree to the subrogation provision of the plan;
5. charges for any illness or injury for which expenses were incurred, services received, or treatment given before the effective date of coverage;
6. health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends;
7. health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan;
8. in the event that a Non-Network provider waives Coinsurance and/or the Annual Deductible for a particular health service, no Benefits are provided for the health service for which the Coinsurance and/or the Annual Deductible are waived;
9. charges in excess of Eligible Expenses or in excess of any specified limitation;
10. services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), when the services are considered medical or dental in nature;
11. non-surgical treatment of obesity, including morbid obesity;
12. surgical treatment of obesity excluding severe morbid obesity (with a BMI greater than 40) except for Class III obesity;
13. growth hormone therapy; 14. sex transformation operations; 15. gender-reversal;
16. custodial Care or maintenance care; 17. domiciliary Care;
18. multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for exacerbation of chronic pain;
19. Private Duty Nursing - Inpatient;
20. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which Benefits are described under Hospice Care in What the UnitedHealthcare Medical Plans Cover section of this Book;
21. rest cures; 22. psychosurgery;
23. treatment of benign gynecomastia (abnormal breast enlargement in males); 24. medical and surgical treatment of excessive sweating (hyperhidrosis);
25. medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea;
26. appliances for snoring; 27. marriage counseling;
28. smoking cessation programs, other than the QuitPower Program;
29. any charges for missed appointments, room or facility reservations, completion of claim forms or record processing;
30. any charges higher than the actual charge. The actual charge is defined as the provider's lowest routine charge for the service, supply or equipment;
31. any charge for services, supplies or equipment advertised by the provider as free;
32. any charges by a provider sanctioned under a federal program for reason of fraud, abuse or medical competency;
33. any charges prohibited by federal anti-kickback or self-referral statutes; 34. services resulting from the commission of a felony;
35. treatment or services when confined in a prison, jail, or other penal institution; 36. examinations or treatment ordered by a court in connection with legal proceedings;
37. items, which have value to the participant in the absence of an illness or injury being treated; 38. chelation therapy, except to treat heavy metal poisoning;
39. any charges by a resident in a teaching Hospital where a faculty Physician did not supervise services; 40. outpatient rehabilitation services, spinal treatment, manipulative treatment or supplies including, but
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which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring;
41. spinal treatment, including chiropractic and osteopathic manipulative treatment, to treat an illness, such as asthma or allergies;
42. speech therapy to treat stuttering, stammering, or other articulation disorders;
43. breast reduction except as coverage is required by the Women's Health and Cancer Right's Act of 1998 for which Benefits are described under Reconstructive Procedures in What the
UnitedHealthcare Medical Plans Cover section of this Book; 44. foreign language and sign language services;
45. panniculectomy, abdominoplasty, thighplasty, brachioplasty, mastopexy, and breast reduction. This exclusion does not apply to Reconstruction - Post-Mastectomy in What the UnitedHealthcare Medical Plans Cover section of this Book;
46. insulin.