|
<br />)
<br />
<br />11.03 Autopsy or postmortem examinations and associated services, including the autopsy.
<br />
<br />11.04 Breast reduction or augmentation. Surgery for the reduction or augmentation of the size of the breasts
<br />except as required for the comprehensive treatment of breast cancer.
<br />
<br />11.05 Complementary or alternative medicine including, but not limited to, self-care or self-help training;
<br />homeopathic medicine and counseling; Ayurvedic medicine such as lifestyle modifications and
<br />purification therapies; traditional Oriental medicine including acupuncture; naturopathic medicine;
<br />environmental medicine including the field of clinical ecology; chelation therapy; therrnography; mind-
<br />body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; hypnotherapy;
<br />prayer and mental healing; manual healing methods snch as the Alexander technique, aromatherapy,
<br />massage therapy including but not limited to: Ayurvedic massage, craniosacral balancing, Feldenkrais
<br />method, Hellerwork, reflexology, rolling, shiatsu, traditional Chinese massage, Trager therapy, trigger-
<br />point myotherapy, and polarity therapy. Reichian therapy, biofield therapeutics; Reiki, SHEN therapy,
<br />and therapeutic touch; bioelectromagnetic applications in medicine; herbal therapies; sleep therapy, sex
<br />therapy, behavioral training, cognitive therapy, and vocational rehabilitation.
<br />
<br />11.06 Complications of any non-covered service, including the evaluation or treatment of any condition that
<br />arises as a complication of a non-covered service.
<br />
<br />11.07 Cosmetic, surgical or non-surgical procedures which are undertaken primarily to improve or
<br />otherwise modify the Member's external appearance arc excluded, except for reconstructive surgery to
<br />correct and repair a functional disorder as a result of a disease, injury. or congenital defect or initial
<br />implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast. Also
<br />excluded are surgical excision or reformation of any sagging skin of any part of the body, including, but
<br />not limited to: the eyelids, face, neck, abdomen, arms, legs, or buttocks; any services performed in
<br />connection with the enlargement, reduction, implantation or change in appearance of a portion of the
<br />body, including, but not limited to: the face, lips, jaw, chin, nose, ears, breasts, or genitals (inclnding
<br />circumcision, except newborns for up to one year from date of birth; see also Section 10.18); hair
<br />transplantation, chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattooing;
<br />or any other surgical or non-surgical procedures which are primarily for cosmetic purposes or to create
<br />body symmetry. Additionally, all medical complications as a result of cosmetic, surgical or non-surgical
<br />procedures are excluded.
<br />
<br />11.08 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids.
<br />
<br />11.09 Custodial Care as defined in Section 2.16.
<br />
<br />11.10 Dental Care, as defined in Section 2.17, for any condition except:
<br />
<br />11.1 0.01 Services, supplies or appliances for Dental Care necessary to promptly repair (but not
<br />replace), sound natural teeth required as a result of and directly related to an accidental
<br />injury sustained while covered under the Plan. Treatment must begin 90 days from date of
<br />injury. Such services are limited to $1,000 per calendar year;
<br />
<br />11.10.02 Reconstructive jaw surgery for the treatment of deforrnities that are present and apparent at
<br />birth; or
<br />
<br />11.1 0.03 Services for the treatment of tumors or full mouth extraction when required before radiation
<br />therapy.
<br />
<br />11.10.04 Treatment must be completed within nine months from date of injury.
<br />
<br />11.11 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
<br />behavioral problems and developmental delays. Expenses for remedial or special education, counseling,
<br />or therapy including evaluation and treatment of the above-listed conditions or behavioral training
<br />whether or not associated with manifest mental disorders or other disturbances.
<br />
<br />)
<br />
<br />)
<br />
<br />33
<br />
<br />A V-CHOlCE-2009
<br />MP-5320 (10/09)
<br />
|