What Expenses Are Not Covered

On This Page...

What Medical and Surgical Expenses Are Not Covered
What Dental Expenses Are Not Covered

Managed Choice POS limits some health care supplies and services as described on previous pages of this summary. The plan also excludes some expenses, even if such an expense could be considered medically necessary. If you do not find an expense listed as covered and the expense is not specifically excluded below, call your claims processing office ahead of time to determine if the expense is covered.

What Medical and Surgical Expenses Are Not Covered

Expenses for the following services, supplies, or treatment are not covered by Managed Choice POS:

• Abortions - unless the abortion is necessary because the life of the mother would be endangered if the fetus is carried to term, or if the pregnancy is the result of rape or incest, or following miscarriage.
• Acupuncture, except for those charges associated with surgical anesthesia.
• Artificial organs - other than limbs, larynx, and eyes - including surgery and related expense for any type of artificial organ transplantation.
• Birth control pills. This exclusion does not apply to in-network benefits.
• Blood or blood plasma which is replaced by or for the patient.
• Caffeine or nicotine intoxication, withdrawal or dependence-related care, including prescription drugs.
• Chiropractic care. This exclusion applies only to out-of-network benefits.
• Company-provided services or supplies or those furnished by you, your spouse, or a child, brother, sister, or parent of you or your spouse, or a person who normally resides in your home.
• Cosmetic surgery, which is surgery performed mainly to change a person's appearance. It includes surgery performed to treat a mental, psychoneurotic, or personality disorder through change in appearance. Services related to complications arising from non-covered cosmetic surgery also are excluded. The following are not considered cosmetic surgery -
  • Surgery to correct the result of an accidental injury sustained while a covered person.
  • Surgery to treat a condition, including a birth defect, which impairs the function of a body organ.
  • Surgery to reconstruct a breast after a mastectomy performed for the treatment of a disease.
• Court-ordered treatment unless it is certified as medically/psychologically necessary.
• Custodial care or maintenance therapy, including care for conditions that are not typically responsive treatment.
• Dental services except as described elsewhere in this booklet. This exclusion encompasses shortening or lengthening the maxilla or mandible for cosmetic purposes or correction of malocclusion and any dental care involved in treatment of Temporomandibular Joint (TMJ) dysfunction/pain syndrome - except for surgery when ordered by a network oral surgeon.

  The exclusion does not apply to a charge made for the treatment or removal of a malignant tumor or the treatment of accidental injury to natural teeth when the charges are for physicians' or dentists' services or X-ray exams and are incurred within 12 months of the accident. "Treatment" includes the replacement of those teeth within that time.

• Educational programs for the mentally impaired or care for developmental disorders, cluttering, or stuttering.
• Expenses above the usual rate. A charge exceeds the usual rate to the extent it is above the usual charge made by the particular provider for the service or supply when there is no benefits coverage.
• Expenses above the prevailing rate. A charge exceeds the prevailing rate to the extent it is above the range of charges generally made in the geographical area for a like service or supply. The plan administrator determines the area and range.
• Foot conditions, specifically physicians' services for
  • A weak, strained, flat, unstable, or imbalanced foot or a metatarsalgia or bunion. This exclusion does not apply to charges for an open cutting operation.
  • One or more corns, calluses, or toenails. This exclusion does not apply to a charge for removal of part or all of one or more nail roots and services in connection with treatment of a metabolic or peripheral vascular disease.
• Government plan charge for a service or supply
  • Furnished by or for the United States government or any other government, unless payment of the charge is required by law or
  • To the extent that the service or supply, or any benefit for the charge, is provided by any law or government plan under which the patient is or could be covered. Expenses for services or supplies that any school system is required by law to provide are excluded; however, this exclusion does not apply to a state plan under Medicaid or to any law or plan when, by law, its benefits are excess to those of any private insurance program or other nongovernmental program.
• Impregnation or fertilization, which includes any of the following, and related charges, that involve either a covered person or a surrogate as a donor or recipient for
  • Artificial insemination, actual or attempted
  • In-vitro fertilization, actual or attempted.
• Medically/psychologically unnecessary services or supplies including tests and check-up exams. "Unnecessary" means such services or supplies are not needed for the diagnosis or medical care of a sickness or injury. To be considered necessary, a service or supply must be determined by the plan administrator to meet all of these tests:
  • It is ordered or approved by a physician.
  • It is recognized throughout the physician's profession as safe and effective, is required for the diagnosis or treatment of the particular sickness or injury, and is employed appropriately in a manner and setting consistent with generally accepted United States medical standards.
  • It is neither educational or vocational nor experimental or investigational in nature.

  For psychiatric and substance abuse network benefits, treatment must also be adequate and essential for the condition and expected to improve the patient's condition or level of functioning in order to be considered necessary.

  Services and supplies which are provided in conjunction with an unnecessary service or supply also will be considered unnecessary. Aetna or Value Options will determine whether a service or supply is unnecessary. The fact that a physician may prescribe, order, recommend or approve a service or supply does not, of itself, make it medically/ psychologically necessary or make the charge a covered expense, even though it is not specifically listed as an exclusion.

  This exclusion for unnecessary services or supplies does not apply to in-network newborn baby care, routine health assessments, or childhood immunizations.

  For out-of-network and out-of-area benefits, a service or supply furnished to a newborn child will be considered medically necessary if the service or supply meets either of these conditions:

  • It is furnished for the medical care of a diagnosed sickness (including a congenital defect or birth abnormality) or injury and meets all of the tests above, or
  • It is furnished during the first 10 days after the child's birth and is for hospital room and board and other supplies and nonprofessional services furnished by the hospital for medical care in that hospital or for the child's first physician visit.
    
    
• Newborn care for the child of a covered dependent child.
• Over-the-counter medication or dietary supplement not requiring a prescription by law.
• Personal comfort and convenience items and services.
• Private duty nursing. This exclusion applies only to out-of-network benefits.
• Reversal of a previous voluntary surgical procedure to induce infertility.
• Sex change surgical procedures (including counseling or therapy).
• Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully developed.
• War, military service, or commission of a crime, which includes charges for a sickness or injury due to war or any act of war, while on active military service, or incurred while committing a crime.
• Work-connected injury or illness including
  • Injury arising out of or in the course of any work for wage or profit (whether or not with the company) when the injury is covered by any workers' compensation law or employers' liability act, whether or not you claim these benefits.
  • Illness arising out of or in the course of any work for wage or profit covered by any workers' compensation law, occupational disease law or similar law, whether or not you claim these benefits.

back to top

What Dental Expenses Are Not Covered

In addition to the preceding list of exclusions, the following dental services, supplies, and treatment are not covered:

• Duplicate dental appliances, including the replacement of a lost, missing, or stolen dental appliance.
• Education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene, or dental plaque control.
• Facings on pontics or crowns posterior to the second bicuspid.
• Orthodontics and appliances or restorations to increase the vertical dimensions or restore occlusion.
• Periodontal splinting of teeth except for provisional, introcoronal stabilization of mobile teeth.
• Precision attachments except when they represent the sole method of completing a course of treatment.
• Tooth implantation or transplantation and surgical insertion of fabricated implants.

back to top