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<br />.,
<br />
<br />) 11.30 Personal comfort items not Medically Necessary for proper medical care as Part of the therapeutic plan
<br />to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to:
<br />wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and
<br />acconunodations, maid services, televisions/radios, telephone charges, photographs, complimentary
<br />meals, birth announcements, take home snpplies, travel expenses (other than Medically Necessary
<br />ambulance services that are provided for in Section 9.01), air conditioners, humidifiers, dehumidifiers,
<br />and air purifiers or filters.
<br />
<br />11.31 Physical examinations or tests, such as premarital blood tests or tests for continuing employment,
<br />education, licensing, or insurance or that are otherwise required by a third party.
<br />
<br />11.32 Physical, speech, occupational, and all otber therapies for chronic conditions. Maintenance therapy
<br />is not covered. Maintenance therapy begins when the therapeutic goals of a treatment plan have been
<br />met and/or no further functional progress is expected. Speech therapy for non-organic or functional
<br />disorders is not covered, except for the initial evaluation to determine the root cause. Examples include
<br />attention deficit disorder, developmental delay, mental retardation; and Down's syndrome. Abnonnal
<br />speech pathology, including but not limited to lisping and stuttering, is not covered.
<br />
<br />Private duty nursing services.
<br />
<br />Rehabilitation programs. Alcohol or substance abuse rehabilitation, vocational rehabilitation,
<br />pulmonary rehabilitation, long tenn rehabilitation, or any other rehabilitation program.
<br />
<br />Removal of benign skin lesions and warts, moles, skin tags, lipomas, keloids, and scars is not covered,
<br />even with a recommendation or prescription by a physician.
<br />
<br />Reversal of sterilization procedures.
<br />
<br />Sexual dysfunction. All medications, devices, and other forms of treatment related to a diagnosis of
<br />sexual dysfunction, regardless of etiology.
<br />
<br />Smoking cessation. Any service or supply to eliminate or reduce dependency on or addiction to
<br />tobacco, including but not limited to: nicotine withdrawal programs, facilities, and supplies (e.g.
<br />transdermal patches, Nicoretle gum).
<br />
<br />11.39 Speech therapy for delayed or abnormal speech pathology.
<br />
<br />11.40 Substance abuse treatment. Treatment for chronic alcoholism and chronic drug addiction, except those
<br />services offered as a basic health service. See Section 10.13.
<br />
<br />0
<br />11.33
<br />11.34
<br />11.35
<br />11.36
<br />11.37
<br />)
<br />11.38
<br />
<br />11.41 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
<br />intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts Dental
<br />appliances, other corrective lenses and hearing aids, including the professional fee for fitting them, are
<br />not covered.
<br />
<br />11.42 Temporomandibular Joint Dysfunction (TMJ). Services related to the diagnosis/treatment of TMJ
<br />except when Medically Necessary; all dental treatment for TMJ.
<br />
<br />11.43 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to
<br />applicable State and Federal laws or as specified in the Elective Tennination of Pregnancy amendment
<br />to the Subscribing Group Contract.
<br />
<br />11.44 Travel expenses including expenses for ambulance services to and from a physician or Hospital except
<br />in accordance with Section 9.01. Ambulance services are not covered when the skill of medically
<br />trained personnel is not required and the Member can be safely transported by other means.
<br />
<br />11.45 Treatment of a condition resulting from:
<br />
<br />11.45.01 Participation in a riot or rebellion;
<br />
<br />36
<br />
<br />A V -CH 01 CE- 2009
<br />MP-5320 (10/09)
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