Blue Cross Blue Shield Vermont: Exclusions

Exclusions

Chiropractic Exclusions
We provide no chiropractic benefits for:

Surgery;

obstetrical procedures, including prenatal and postnatal
care;

prescription or administration of drugs;

supplies or durable medical equipment;

treatment of a mental health condition;

maintenance therapy or therapy for a chronic condition when the therapeutic
goals of a treatment plan have been achieved and no additional progress is
apparent or expected to occur;

treatment of any visceral condition, that is a dysfunction of
the abdominal or thoracic organs, or other conditions that are not neuromusculoskeletal
in nature;

any other procedure not listed above; or

services by a non-Network provider.

Dental Exclusions
We provide no benefits for:

tooth implants (except for treatment of accidental

injury within six months of the accident);

care for periodontitis;

injury as a result of chewing or biting;

pre- and post-operative dental care (we consider most pre- and post-operative
visits part of the surgical benefit, so we do not provide additional benefits
for these services);

orthodontics (including orthodontics performed as an adjunct to orthognathic
surgery);

procedures designed primarily to prepare the mouth for dentures (including
alveolar augmentation, bone grafting, frame implants, and ramus mandibular
stapling); or

any other dental care not specifically covered in
your certificate above.

Home Care Exclusions
We provide no Home Care benefits for:

dietitian services;

homemaker services;

Chronic care;

drugs or medications;

maintenance therapy;

Custodial Care;

food or home-delivered meals; and

private duty nursing services provided at the same
time as home health care nursing services.

Mental Health Exclusions
We provide no Mental Health benefits for:

treatment of Chronic conditions, except for related Acute episodes;

treatment for willfully uncooperative or intractable patients

Custodial Care;

treatment for conditions related to autistic disease of childhood (ICD-9-CM
code 299.00) or mental retardation (ICD-9-CM codes 317.00 through 319.99),
except interventions for Acute, brief episodes, when other diagnoses are present;

treatment for conditions related to hyperkinetic syndromes (ICD-9-CM codes
314.00 through 314.99) or behavioral problems, except intervention for Acute,
brief episodes, when other diagnoses are present; and

treatment for conditions related to specific delays
in development and learning disabilities (ICD-9-CM codes 315.00 through 315.99)
and psychic factors associated with diseases classified elsewhere in ICD-9-CM
(ICD-9-CM code 316.00).

Office Visit Exclusions
We do not cover:

bulk immunizations (those provided to a group of people) unless you get Prior Approval;

immunizations mandated by law to be provided by an employer;

dental exclusions listed above.

Speech Therapy Exclusions
We do not cover Speech Therapy for speech loss or impairment due to:

a functional nervous/psychiatric disorder;

mental retardation;

nonphysical conditions (such as learning disabilities, stuttering, alcoholism);
or

developmental delays (including lack of normal physiological
development, infantile cerebral palsy, multiple sclerosis, hyperkinetic syndrome
of childhood, myoneural disorders, and hearing loss or disorder).

Substance Abuse Exclusions
We provide no Substance Abuse treatment benefits for:

Chronic conditions, except for related Acute episodes;

treatment we do not approve in advance; or

treatment for willfully uncooperative or intractable
patients.

Transplant Exclusions
We provide no benefits for the purchase price of any organ or bone marrow that is sold rather than donated.

Visions Exclusions

We do not cover services or supplies for:

orthoptics, vision training or Plano (nonprescription) lenses;

vision materials (lenses, frames, etc.) unless your
group has purchased a vision materials rider; and

any eye examination or corrective eyewear required
by an employer as a condition of employment.

General Exclusions
1.Services or supplies that must be Covered by a prior health plan as extended benefits.

2. Services or supplies for which you would have no legal obligation to pay if you did not have your Contract or similar coverage.

3. Services or supplies for which there is no charge.

4. Services or supplies paid directly or indirectly by a local, state or federal government agency, except as otherwise provided by law.

5. Services or supplies you require as a result of your commission or attempt to commit a felony, or your engagement in an illegal occupation.

6. Services or supplies in excess of the limitations or maximums set forth in your Contract.

7. Services or supplies we determine are not Medically Necessary.

8. Services or supplies that we determine are Investigational, mainly for research purposes or Experimental in nature.

9. Services or supplies that are not provided in accordance with accepted professional medical standards in the United States.

10. Acupuncture, acupressure or massage therapy; hypnotherapy, rolfing, homeopathic remedies.

11. Automatic ambulatory home blood pressure monitoring.

12. Biofeedback or other forms of self-care or self-help training.

13. Blood or its derivatives; self-donations and storage.

14. Chronic care (see Definitions), maintenance care or treatment of conditions that will not respond favorably to treatment.

15. (Routine) circumcision.

16. Clinical ecology, environmental medicine, Inpatient confinement for environmental change or similar treatment.

17. Cognitive retraining and educational programs, except for diabetes education.

18. Communication devices and communication augmentation devices.

19. Consultations except when they occur between Providers and the Providers attach a written report to the patient’s medical record.

20. Correction of near- or farsighted conditions or aphakia (where the lens of the eye is missing either congenitally, accidentally or has been surgically removed, as with cataracts) by means of corneal microsurgery or “laser Surgery,” such as keratomileusis, keratophakia, and radial keratotomy and all related services.

21. Cosmetic procedures and supplies that are not Reconstructive.

22. Custodial Care, domiciliary care or rest cures.

23. Dental care, services and supplies and oral Surgery, unless specifically provided by your Contract.

24. Drugs and pharmaceuticals which you purchase on an Outpatient basis (unless your Group purchases a Prescription Drug Rider).

25. Durable Medical Equipment, prosthetics, orthotics and Medical/Surgical Supplies (unless your Group purchases a Medical Equipment/Supplies Rider).

26. Routine eye care unless you have a vision exam rider. Eye exercises or visual training.

27. Eyeglasses or contact lenses unless you need them to replace the lens of an eye (and the lens was not replaced at the time of surgery) and you have a Medical Equipment/Supplies Rider or a Vision Materials Rider.

28. Educational evaluation or therapy, except for treatment of diabetes, such as medical nutrition therapy by approved Network Providers.

29. Foot care or supplies that are palliative or Cosmetic in nature, including supportive devices and treatment for bunions (except capsular or bone Surgery), flat-foot conditions, subluxations of the foot, corns, callouses, toenails, fallen arches, weak feet, Chronic foot strain, and symptomatic complaints of the feet.

30. Hearing aids or examinations for the prescription or fitting of hearing aids.

31. Home or automobile modifications like air conditioners, HEPA filters, humidifiers, stair glides, elevators, lifts or “barrier-free” construction, even if prescribed by a Provider.

32. Illnesses or injuries which are:

a result of an act of war within the United States, its territories or possessions;

sustained in active military service; or

sustained during combat, unless otherwise required by law.

33. Facility charges for Inpatient stays that begin before your effective date.

34. Institutional or Custodial Care for the physically or mentally handicapped.

35. Mandated treatment, including court-ordered treatment, unless such treatment is Medically Necessary, ordered by a Physician and Covered under your Contract.

36. Nonmedical charges, such as:

a penalty for failure to keep a scheduled visit; or

fees for completion of a claim form.

37. Nutritional formulae, except for up to $2,500 per year for “medical foods” prescribed for the Medically Necessary treatment of an inherited metabolic disease or those administered through a feeding tube.

38. Orthodontics.

39. Pain management programs.

40. Personal hygiene items.

41. Personal service or comfort items.

42. Physical fitness equipment, weight loss programs and health club memberships.

43. Support therapies, including pastoral counseling, assertiveness training, dream therapy, music or art therapy, recreational therapy, smoking cessation therapy, and stress management.

44. More than one attempt at reversal of sterilization.

45. Telephone consultations (between Provider and patient).

46. TENS (transcutaneous electrical nerve stimulation) units, except with written Prior Approval from us. (Note: We will not approve a TENS unit to treat headache, pelvic or deep abdominal pain or jaw pain.)

47. Therapy services provided as a part of Chronic pain control, developmental, pulmonary or other form of rehabilitation, except:

treatment of diabetes by a Network Provider; or

upon prior written approval by the Plan.

48. Travel (other than ambulance transport), even if prescribed by a Physician.

49. Treatment for conditions related to autistic disease of childhood (ICD-9-CM code 299.00) or mental retardation (ICD-9-CM codes 317.00 through 319.99), except interventions for Acute, brief episodes when other diagnoses are present.

50. Treatment for conditions related to hyperkinetic syndromes (ICD-9-CM codes 314.00 through 314.99) or behavioral problems, except interventions for Acute, brief episodes when other diagnoses are present or the use of Prescription Drugs to treat Attention Deficit Hyperactivity Disorder (ICD-9-CM code 314.01).

51. Treatment for conditions related to specific delays in development and learning disabilities (ICD-9-CM codes 315.00 through 315.99) and psychic factors associated with diseases classified elsewhere in ICD-9-CM (ICD-9-CM code 316.00).

52. Evaluation and treatment leading to, or in connection with, artificial insemination, in vitro fertilization, embryo transplantation and gamete intrafallopian transfer (GIFT). This exclusion does not apply to infertility evaluation.

53. Treatment leading to, or in connection with, transsexual Surgery.

54. Treatment of obesity, except prescription drug treatment if you have a prescription drug rider or surgical treatment when:

your Physician determines that your Body Mass Index
is over 40 (according to Table 1 in the “Methods for Voluntary Weight
Loss and Control” booklet
by the National Institute of Health Technology Assessment Conference Statement
of March 1992);

you have other medical conditions that could be significantly and adversely
affected by this degree of obesity; and

we approve your treatment in advance.

55. Work-related illnesses or injuries (or those which you claim to be work-related, until otherwise finally adjudicated) and those which are (or by law should be) covered by Workers' Compensation.

56. Services and supplies not specifically described as Covered.

Provider Exclusions

Also, your Contract does not Cover services or supplies prescribed or provided by a:

57. Provider that we do not approve for the given service or who is not defined in our “Definitions” section as a Provider.

58. Professional who provides services as part of his or her education or training program.

59. Member of your immediate family.

60. Veterans Administration Facility treating a service-connected disability.

61. Nonparticipating Provider if we require Participation as a condition for coverage under your Certificate.

62. Non-Network Provider if we require Network participation as a condition for coverage under your Certificate.