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<br />XU. EXCLUSIONS FROM BASIC BENEFITS
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<br />Medical Services and benefits for the following classifications and conditions are Dot covered and are excluded
<br />from the Schedule of Basic Benefits provided under this Contract:\
<br />
<br />12.01 Aids or devices that assist with nonverbal communications, including but not limited to
<br />communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal
<br />Digital Assistants (PDAs) Braille typewriters, visual alert systems for the deaf and memory books.
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<br />12.02 Autopsy or postmortem examinatinns and associated services, including the autopsy.
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<br />12.03 Breast reduction or augmentatinn. Surgery for the reduction or augmentation of the size of the breasts
<br />except as required for the comprehensive treatment of breast cancer.
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<br />12.04 Complementary or alternative medicine including, but not limited to, self-care or self-help training;
<br />horneopathic 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; thermography; mind-
<br />body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; hypnotherapy;
<br />prayer and mental healing; manual healing methods such as the Alexander teclmique, aromatherapy,
<br />massage therapy including but not limited to: Ayurvedic rnassage, craniosacral balancing, Feldenkrais
<br />method, Hellerwork, reflexology, rolfmg, 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.
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<br />12.05 Complications of any non-covered service, including the evaluation or treatment of any condition that
<br />arises as a complication of ~ non-covered service.
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<br />12.06 Cosmetic, surgical or non-surgical procedures which are undertaken primarily to improve or
<br />otherwise modify the Member's external appearance are 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 (including
<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 cornplications as a result of cosmetic, surgical or non-surgical
<br />procedures are excluded.
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<br />12.07 Cosmetics, dietary supplements, nutritional formnlae, health or beauty aids.
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<br />12.08 Custodial Care (as defmed in Part III, Section 3.13).
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<br />12.09 Dental Care, as defined in Section 3.11, for any condition except:
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<br />12.09.01 When such services are for the treatment of trauma related fractures of the jaw or facial
<br />bones or for the treatment of tumors;
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<br />A V-GlOO-2009
<br />MP-5319 (10/09)
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