Related Exclusions. This agreement does NOT cover custodial care, respite care, day care, or care in a facility that is not approved by us. See
Related Exclusions. This agreement does NOT cover: • hospital or other facility’s services for treatment received in an emergency room for a non-emergency condition; • follow-up visits to the emergency room; or • dental injuries incurred as a result of biting or chewing.
Related Exclusions. Hearing aid coverage does NOT include batteries, repairs, modifications, cords, and other assistive listening devices.
Related Exclusions. This agreement does NOT cover any homemaking, companion, or chronic (custodial) care services.
Related Exclusions. This agreement does NOT cover infertility treatment for a person that previously had a voluntary sterilization procedure.
Related Exclusions. This agreement does NOT provide coverage for: • air or water ambulance transportation unless the destination is an acute care hospital. (Some examples of non- covered air or water ambulance services include transport to a physician’s office, nursing facility, or a patient’s home); and • transport from cruise ships when not in United States waters.
Related Exclusions. This agreement does not provide coverage for enteral formula taken orally without a written order from the doctor and unless for the treatment of the conditions listed above. This agreement does not cover enteral formula taken orally unless for home use. Modified low protein food products are not covered unless for the treatment of the conditions listed above.
Related Exclusions. This agreement does NOT cover: • massage therapy, aqua therapy, maintenance therapy, and aromatherapy; • therapies, procedures, and services for the purpose of relieving stress; • pillows;
Related Exclusions. This agreement does NOT cover: • any homemaking, companion, or chronic (custodial) care services; • the services of a personal care attendant; • charges for private duty nursing when primary duties are limited to bathing, feeding, exercising, homemaking, giving oral prescription drugs or acting as a companion; OR • services of a private nurse who is a member of your home or the cost of any care provided by one of your relatives (by blood, marriage, or adoption).
Related Exclusions. This agreement does NOT cover any treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigative except as described above. Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services will be recognized as having been proven effective in clinical medicine only if one of the following apply: • final approval for the use of a specific service for a specific condition from the appropriate governmental regulatory body; • demonstrated, reliable evidence based upon an entry in at least one of the three standard reference compendia (shown in this Section 3.11); • sound scientific studies published in authoritative, peer reviewed medical journals that: • show statistically significant outcomes about the effectiveness of the service, and • permit a consensus of opinion that the service improves the member’s net health outcome, and • show it is as beneficial as any established alternatives, and • show that the improvement is attainable outside the investigational setting; or • the determination by an expert medical consultant retained by us, for the purpose of reviewing a particular service, that the service is not experimental/investigational for that particular member’s case. A service is considered experimental/investigational, and therefore excluded, if one or more of the following circumstances are true: • The service is the subject of ongoing Phase I or Phase II clinical trial or is the experimental arm of Phase III clinical trial, except as described above. • Is under study to determine the maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis. • The prevailing opinion among experts about the service is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. • The current belief in the pertinent specialty of the medical profession in the United States is that the service or supply should not be used for the diagnosis or indications being requested outside of clinical trials or other research settings because it requires further evaluation for that diagnosis or indications. We will determine the applicability of this criterion based on: • Published reports in authoritative, peer-reviewed medical literature; and • Reports, publications, ...
