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artificial or mechanical hearts;
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cardiac or pulmonary rehabilitation
-
chiropractic expense involving:
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care performed on a non-acute, asymptomatic basis;
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care primarily for your convenience;
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office visits other than for the initial evaluation;
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supportive care performed primarily to maintain the level of correction already achieved; and
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other services that don't meet Group Health clinical criteria for being medically necessary;
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complications of non-covered surgical services;
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conditions resulting from service in the armed forces during a declared or undeclared war or voluntary participation in a riot, insurrection or act of terrorism;
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convalescent or custodial care;
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corrective appliances or artificial aids, including eyeglasses, contact lenses or services related to their fitting, except as described under "Hearing Aids";
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cosmetic services, including treatment of complications from cosmetic surgery that is elective or not covered;
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court-ordered services or programs not judged medically necessary by the network provider;
-
dental care, oral surgery, and dental services and appliances, except as described under "Physician and Other Medical/Surgical Services";
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diabetic meals and some diabetes education materials;
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evaluations and surgical procedures to correct refractions not related to eye pathology;
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exams, tests or shots required for work, insurance, marriage, adoption, immigration, camp, volunteering, travel, licensing, certification, registration, sports, recreational or school activities;
-
experimental or investigational treatment;
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gambling addiction or other specialty treatment programs;
-
genetic testing and related services unless determined medically necessary by Group Health's medical director;
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hearing aid replacement parts, batteries and maintenance costs;
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herbal supplements;
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home health care services involving:
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any care provided by a member of the patient's family;
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any other services rendered in the home that aren't specifically listed as covered under "Home Health Care";
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care in a nursing home or convalescent facility;
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custodial care or maintenance care;
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housekeeping or meal services; and
-
private duty or continuous nursing care in the patient's home;
-
home pregnancy tests;
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hospice services involving:
-
any services provided by members of the patient's family;
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custodial care or maintenance care;
-
financial or legal counseling (e.g., estate planning or will preparation);
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funeral arrangements; and
-
homemaker, caretaker or other services not solely related to the patient, such as:
-
hypnotherapy or any related services;
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infertility treatment; sterility; or sexual dysfunction diagnostic testing or treatment, including Viagra; penile implants; vascular or artificial reconstruction; and procedures to reverse voluntary sterilization;
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injury to teeth;
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jaw abnormalities or malocclusions;
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medicine or injections for anticipated illness while traveling;
-
mental health services involving:
-
custodial care;
-
day treatment;
-
marital and family counseling;
-
specialty programs for mental health therapy not provided by Group Health; and
-
treatment of sexual disorders;
-
neurodevelopmental and rehabilitation services involving:
-
implementation of home maintenance programs;
-
long-term rehabilitation programs;
-
physical, occupational or speech therapy services when available through programs offered by public school districts;
-
programs for the treatment of learning problems;
-
recreational, life-enhancing, relaxation or palliative therapy;
-
specialty rehabilitation programs not provided by Group Health; and
-
therapy for degenerative or static conditions when the expected outcome is primarily to maintain the patient's level of functioning;
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non-emergency use of an emergency facility;
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organ transplant costs involving donor costs reimbursable by the organ donor's insurance plan, and living expenses and transportation expenses not listed under "Transplants";
-
orthopedic shoes not attached to an orthopedic appliance or arch supports (including custom shoe inserts or their fitting, except for therapeutic shoes and shoe inserts for severe diabetic foot disease);
-
orthoptic (i.e., eye training) therapy;
-
out-of-network expenses exceeding usual, customary and reasonable (UCR) charges;
-
over-the-counter drugs (i.e., medicines and devices not requiring a prescription), except for tobacco cessation drugs;
-
personal comfort items, such as phones or television;
-
physical exams, immunizations or evaluations primarily for the protection and convenience of third parties, including for obtaining or continuing employment or insurance or government licensure;
-
pre- and post-surgical nutritional counseling and related weight-loss programs;
-
prescribing and monitoring of drugs;
-
prescription drugs, specifically:
-
dietary drugs;
-
drugs for cosmetic uses;
-
drugs for treatment of sexual dysfunction;
-
drugs not approved by the FDA and in general use as of March 1 of the previous year;
-
over-the-counter drugs; and
-
vitamins, including prescription vitamins;
-
preventive care visits to acupuncturists and naturopaths, and services not within the scope of their license;
-
rehabilitative services involving:
-
chronic conditions;
-
implementation of home maintenance programs;
-
physical, occupational or speech therapy services when available through programs offered by public school districts;
-
programs for the treatment of learning problems;
-
recreational, life-enhancing, relaxation or palliative therapy;
-
specialty treatment programs not provided by Group Health; and
-
therapy for degenerative or static conditions when the expected outcome is primarily to maintain the patient's level of functioning;
-
routine foot care;
-
services and supplies covered by other insurance policies, including any vehicle, homeowner's, property or other insurance policy whether or not a claim is made pursuant to:
-
medical coverage, medical "no fault" coverage, personal injury protection coverage or similar medical coverage contained in the policy; and/or
-
uninsured motorist or underinsured motorist coverage contained in the policy;
-
services and supplies resulting from the loss or willful damage to covered appliances, devices, supplies or materials provided by Group Health;
-
services performed by a network provider or oral surgeon involving:
-
reduction of a fracture or dislocation of the jaw or facial bones;
-
excision of tumors or cysts of the jaw, cheeks, lips, tongue, gums, roof or floor of the mouth; and
-
incision of salivary glands and ducts, and accidental injury to teeth;
-
services covered by the national health plan of any other country;
-
services provided by government agencies, except as required by federal or state law;
-
sexual disorder treatment;
-
TMJ-related expenses involving:
-
orthognathic (jaw) surgery in the absence of a TMJ diagnosis or severe obstructive sleep apnea diagnosis, except for newborn infants with congenital anomalies; and
-
treatment for cosmetic purposes;
-
transplant costs and services involving:
-
donor costs reimbursable by the organ donor's insurance plan;
-
living expenses;
-
transportation expenses (except as listed under "Transplants"); and
-
treatment of donor complications;
-
weight reduction programs and/or exercise programs and specialized nutritional counseling; and
-
work-incurred injury, illness or condition treatment.
