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alternative care (including acupuncture, hypnotherapy and massage therapy) if it's not medically necessary and/or not prescribed by a health care provider;
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benefits covered by the following agencies or programs or benefits that would be covered by these agencies or programs if KingCareSM didn't cover them, except as required by law:
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any federal, state or government program (except for facilities in Aetna's list of network providers);
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government facilities outside the service area;
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Medicare; and
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workers' compensation or state industrial coverage;
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benefits payable under any automobile, medical personal injury protection, homeowner, commercial premises coverage or similar contract (reimbursement to Aetna is made without reduction for any attorney's fees, except as specified in the contract);
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biofeedback;
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charges exceeding reasonable and customary (R&C) rates;
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charges that, without this plan, would not have to be paid, such as services performed by a dependent;
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chiropractic spinal manipulations under anesthesia;
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cosmetic surgery except:
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for a dependent child's congenital anomalies;
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for all stages of reconstruction on a non-diseased breast to make it equal in size to the reconstructed diseased breast following mastectomy;
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for reconstructive breast surgery on the diseased breast necessary because of a mastectomy; and
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when related to a disfiguring injury;
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court-ordered services or programs not judged medically necessary by the plan;
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custodial care solely to assist with normal daily activities (such as dressing, feeding and ambulation) or any other treatment that doesn't require the services of a registered nurse or licensed practical nurse;
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dental charges, except for natural teeth injured in an accident while covered by the plan (this treatment must be within one year of the accident);
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exams, tests or shots required for work, insurance, marriage, adoption, immigration, camp, volunteering, travel, licensing, certification, registration, sports or recreational activities;
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experimental or investigational services, supplies or settings determined to be experimental or investigational because:
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there are insufficient outcomes data available from controlled clinical trials published in peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury involved;
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FDA approval, if required, hasn't been granted for marketing;
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a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or
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the written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment, or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental, investigational or for research purposes;
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fertility services, such as:
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any fees related to donors, donor sperm and banking services;
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drugs to treat infertility—for example, menotropins such as Pergonal;
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procedures to reverse voluntary sterilization;
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fertility services for dependent children;
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sexual dysfunction treatment or related diagnostic testing;
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some assisted reproductive technology (ART) methods;
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surrogate parenting fees; and
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voluntary removal of birth control devices implanted under the skin—for example, Norplant;
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foot care considered routine, such as:
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arch supports or orthotics unless needed for diabetes or other covered conditions;
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corrective orthopedic shoes;
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hygienic care;
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removal of corns or calluses; and
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treatment for flat feet;
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home health care services involving:
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custodial care, except by home health aides as ordered in the approved plan of treatment;
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housecleaning;
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services or supplies not included in the written plan of treatment;
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services provided by a person who resides in your home or is a dependent; and
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travel costs or transportation services;
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hospice care services involving:
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any services provided by members of the patient's family;
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financial or legal counseling, such as estate planning or the drafting of a will;
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funeral arrangements;
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homemaker, caretaker or other services not solely related to the patient, such as:
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more than 120 hours of respite care in any three months of hospice care;
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hospital inpatient convalescent, custodial or domiciliary care;
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hospitalization solely for diagnostic purposes when not medically necessary;
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injuries to teeth caused by biting or chewing;
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injuries sustained:
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by an intentional overdose of a legal prescription, over-the-counter drug, illegal drug or other chemical substance;
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from suicide or attempted suicide (unless the patient was being treated by a mental health professional immediately before or after the attempt);
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while engaged in any activity that results in a felony conviction; or
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while performing any acts of violence or physical force;
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maternity treatment, services or drugs for a dependent child;
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maternity-related services such as home pregnancy tests, Lamaze classes and maternity care for children;
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mental health services involving:
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biofeedback;
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custodial care;
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specialty programs for mental health therapy not provided by KingCareSM; and
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treatment of sexual disorders;
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non-approved drugs and substances (those the FDA has not approved for general use and labeled "Caution—Limited by federal law to investigational use");
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services and supplies not medically necessary to treat illness or injury, except for newborns and unless otherwise specified;
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services of a provider related to you by blood, marriage, adoption or legal dependency;
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services or expenses related to schools or other non-medical facilities that primarily supply educational, vocational, custodial and/or rehabilitative support training or similar services;
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sexual dysfunction or transsexualism surgery, treatment or prescriptions;
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skilled nursing facility services involving:
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custodial care;
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services or supplies not included in your physician's written plan of treatment;
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services provided by a person who resides in your home or is a dependent;
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skilled nursing facility confinement for developmental disability, mental conditions or primarily domiciliary, convalescent or custodial care; and
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travel costs;
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smoking cessation-related inpatient services, books or tapes, or vitamins, minerals or other supplements;
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third-party required treatment or evaluations such as those for school, employment, flight clearance, summer camp, insurance or court;
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treatment (inpatient or outpatient) of chronic mental health conditions such as mental retardation, mental deficiency or forms of senile deterioration resulting from service in the armed forces, declared or undeclared war or voluntary participation in a riot, insurrection or act of terrorism;
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transplant costs and services involving:
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donor costs for a transplant not covered under the plan, or for a recipient who isn't a plan member (however, complications and unforeseen effects from a plan member's organ or bone marrow donation are covered);
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donor costs for which benefits are available under other group coverage;
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non-human or mechanical organs unless deemed non-experimental and non-investigational by the plan; and
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organ or bone marrow search or selection costs, including registry charges, unless described as covered;
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vision tests unless due to illness or injury. The plan also doesn't cover:
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contact lenses (except for cataract surgery);
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eyeglasses or their fittings;
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orthoptics;
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radial keratotomy or similar surgery for treating myopia; and
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visual analysis, therapy or training.
