Index (BMI) classifications of the National Heart, Lung,
and Blood Institute (NHLBI) guideline is covered only at
approved centers if the services are demonstrated, through
existing peer-reviewed, evidence-based, scientific literature
and scientifically based guidelines, to be safe and effective
for treatment of the condition. Clinically severe obesity is
defined by the NHLBI as a BMI of 40 or greater without
comorbidities, or 35-39 with comorbidities. The following
are specifically excluded:
• medical and surgical services to alter appearances or
physical changes that are the result of any surgery
performed for the management of obesity or clinically
severe (morbid) obesity; and
• weight loss programs or treatments, whether prescribed or
recommended by a Physician or under medical
supervision.
• reports, evaluations, physical examinations, or
hospitalization not required for health reasons, including but
not limited to employment, insurance or government
licenses, and court-ordered, forensic or custodial
evaluations, unless otherwise covered under this plan.
• court-ordered treatment or hospitalization, unless treatment
is prescribed by a Physician and is a covered service or
supply under this plan.
• infertility services including infertility drugs, surgical or
medical treatment programs for infertility, including in vitro
fertilization, gamete intrafallopian transfer (GIFT), zygote
intrafallopian transfer (ZIFT), variations of these
procedures, and any costs associated with the collection,
washing, preparation or storage of sperm for artificial
insemination (including donor fees). Cryopreservation of
donor sperm and eggs is also excluded from coverage.
• reversal of male and female voluntary sterilization
procedures.
• any services or supplies for the treatment of male or female
sexual dysfunction such as, but not limited to, treatment of
erectile dysfunction (including penile implants), anorgasmy,
and premature ejaculation.
• medical and Hospital care and costs for the child of your
Dependent child, unless the child is otherwise eligible under
this plan.
• non-medical counseling and/or ancillary services, including
but not limited to Custodial Services, educational services,
vocational counseling, training and, rehabilitation services,
behavioral training, biofeedback, neurofeedback, hypnosis,
sleep therapy, return to work services, work hardening
programs and driver safety courses.
• therapy or treatment intended primarily to improve or
maintain general physical condition or for the purpose of
enhancing job, school, athletic or recreational performance,
including but not limited to routine, long term, or
maintenance care which is provided after the resolution of
the acute medical problem and when significant therapeutic
improvement is not expected.
• consumable medical supplies other than ostomy supplies
and urinary catheters. Excluded supplies include, but are not
limited to bandages and other disposable medical supplies,
skin preparations and test strips, except as specified in the
“Home Health Care Services” or “Breast Reconstruction
and Breast Prostheses” sections of this plan.
• private Hospital rooms and/or private duty nursing except as
provided under the Home Health Care Services provision.
• personal or comfort items such as personal care kits
provided on admission to a Hospital, television, telephone,
newborn infant photographs, complimentary meals, birth
announcements, and other articles which are not for the
specific treatment of an Injury or Sickness.
• artificial aids, including but not limited to corrective
orthopedic shoes, arch supports, elastic stockings, garter
belts, corsets, dentures and wigs.
• hearing aids, including but not limited to semi-implantable
hearing devices, audiant bone conductors and Bone
Anchored Hearing Aids (BAHAs). A hearing aid is any
device that amplifies sound.
• aids or devices that assist with non-verbal communications,
including but not limited to communication boards, pre-
recorded speech devices, laptop computers, desktop
computers, Personal Digital Assistants (PDAs), Braille
typewriters, visual alert systems for the deaf and memory
books.
• eyeglass lenses and frames, contact lenses and associated
services (exams and fittings) (except for the initial set after
treatment of keratoconus or following cataract surgery).
• routine refractions, eye exercises and surgical treatment for
the correction of a refractive error, including radial
keratotomy.
• acupuncture.
• all non-injectable prescription drugs, unless Physician
administration or oversight is required, injectable
prescription drugs to the extent they do not require
Physician supervision and are typically considered self-
administered drugs, non-prescription drugs, and
investigational and experimental drugs, except as provided
in this plan.
• routine foot care, including the paring and removing of
corns and calluses and toenail maintenance. However, foot
care services for diabetes, peripheral neuropathies and
peripheral vascular disease are covered when Medically
Necessary.