15CHIP0023 CHIP EXCLUSIONS BK.Indd

2015

Exclusions for free, low-cost, and full-cost members

UPMC for Kids™ Exclusions for free and low-cost members

Not all services, supplies, or charges are Covered Services. • Inpatient or outpatient treatment related to Except as specifically provided in UPMC for Kids Summary intellectual disability, pervasive development of Benefits (located in the UPMC for Kids Member disorder, or autism that extends beyond traditional Handbook), no benefits will be provided for the following medical management. services, supplies, and charges, including, but not limited to: • Long-term residential treatment services for 1. Alternative Medicine: Including, but not limited to, substance-related disorders such as substance acupuncture and acupressure, aromatherapy, aversion abuse or substance dependency. therapy, ayurvedic medicine, bioenergetic therapy, • Marriage or family counseling, except when carbon dioxide therapy, confrontation therapy, crystal rendered in connection with services provided for healing therapy, cult deprogramming, electric aversion a treatable mental disorder (behavioral health or therapy for alcoholism, expressive therapies such as substance abuse). art or psychodrama, guided imagery, herbal medicine, homeopathy, hyperbaric therapy, massage therapy, • Methadone maintenance for the treatment of narcotherapy, naturopathy, orthomolecular therapy, chemical dependency. primal therapy, relaxation therapy, transcendental • Psychiatric/Psychological and neuro-psychological meditation and yoga, and equestrian therapy. testing for a) learning disabilities/problems, b) school-related issues, c) the purposes of obtaining 2. Assisted Fertilization: Artificial conception or maintaining employment, d) purposes of processes such as, but not limited to, GIFT, ZIFT, submitting a disability application for a mental embryo transplants, and in vitro fertilization. or emotional condition, and e) any other testing that does not require administration by a licensed 3. Behavioral Health Services: behavioral health professional. • Any service related to disorders that are not treatable Diagnostic and Statistical Manual of • Psychoanalysis or other therapies that are not short- Mental Disorders (DSM) defined mental disorders term or crisis-oriented and do not relate to treatable according to the most recent version of DSM. and defined mental disorders according to the most Examples include, but are not limited to, nicotine recent version of DSM. dependence, caffeine intoxication, stuttering, • Sensitivity training. tension headache, stress reaction, reading disorder, • Treatment for personality disorders as the primary mathematics disorder, pathological gambling, diagnosis, learning disabilities, or behavioral disorder of written expressions, expressive/ problems for those conditions. receptive language disorder, phonological disorder, developmental coordination disorder, learning • Treatment of organic disorders, including, but not disorder, sleep disorder, sex therapy, and V-codes. limited to, organic brain disease. • Autism Spectrum Disorder: Coverage for autism • Treatment of chronic behavioral conditions once spectrum disorder is limited to a maximum benefit the individual has been restored to the pre-crisis of $36,000 per member per benefit year. Please level of function. Coverage is provided until the see the UPMC for Kids’ Member Handbook for an behavioral health condition is stable with no chance explanation of what services are covered for the of improvement. diagnostic assessment and treatment of autism • Treatment of chronic pain management programs spectrum disorder. or any related services under the behavioral health • Behavioral health services not expected to result benefit when the primary diagnosis is pain. in demonstrable improvement in the member’s • Treatment of stress, co-dependency, and sexual condition and/or level of function, and chronic addiction; sedative action electrostimulation maintenance therapy, except in the case of serious therapy. mental illness/disorders. • Truancy or disciplinary problems alone.

1 • Twelve-step model programs as sole therapy for educational services, convalescent care, dietary problems, including, but not limited to, eating services, homemaker services, maintenance therapy, disorders or addictive gambling. and food or home-delivered meals. • Vagus nerve stimulation for the treatment of 11. Dental Services: The following are dental care depressive disorders. exclusions: 4. Biofeedback Treatment: Biofeedback treatment • Cases involving covered services in which the for pediatric dysfunctional elimination is limited to dentist and member select a more expensive members from ages 5 to 18 with a maximum of 10 course of treatment than is customarily provided visits per lifetime. by the dental profession consistent with sound professional standards of dental practice for the 5. Chiropractic Care and Related Services. dental condition concerned. Payment under UPMC for Kids will be based on the provider-negotiated 6. Comfort/Convenience Items: Health club fees under UPMC for Kids. memberships, air conditioners, televisions, telephones, • Duplicate and temporary devices, appliances, dehumidifiers, air purifiers, food blenders, exercise and services. equipment, orthopedic mattresses, home or automobile modifications, whirlpools, barber or • Implantology and related services. beauty service, guest service, or similar items, even if • Labial veneers and laminates done for cosmetic recommended by a physician. purposes. However, if performed for restorative purposes, labial veneers and laminates are covered 7. Corrective Appliances: Corrective appliances under the same conditions and to the same primarily intended for athletic purposes or those extent that amalgam and composite restorations related to a sports medicine treatment plan, and are covered. other appliances/devices, and any related services, including, but not limited to, children’s corrective • Local anesthesia when billed for separately by shoes, arch supports, special clothing or bandages a dentist. of any type, back braces, lumbar corsets, hand • Oral surgery which is performed under the medical splints, and shoe inserts and orthopedic shoes, portion of benefits. unless the shoe inserts or orthopedic shoes are • Plaque control programs and oral hygiene and required specifically due to diabetes or peripheral dietary instruction. vascular disease. • Procedures to alter vertical dimension and/or 8. Cosmetic Surgery or Other Procedures: Cosmetic restore or maintain the occlusion. Such procedures surgery or other procedures to repair or reshape a include, but are not limited to, equilibration, body structure for the improvement of the person’s periodontal splinting, full mouth rehabilitation, appearance or for psychological or emotional reasons, restoration of tooth structure lost from attrition, and from which no improvement or physiological and restoration for malalignment of teeth. function can be expected, except for surgery or • Retainer replacement. services which are required to be covered by law, including, but not limited to, removal, revision, • Services covered under the medical portion of or reduction of port wine stains; augmentation UPMC for Kids benefits. procedures; reduction procedures (including male • Services submitted by a professional provider and gynecomastia); scar revisions; or otoplasty. a dentist that are the same services performed on the same dates for the same patient. 9. Court Ordered: Court-ordered services when not • Treatment of temporomandibular joint syndrome medically necessary for the member’s medical or (TMJ) with intra-oral devices or any other method behavioral health condition, as determined by the to alter vertical dimension. member’s physician. 12. Drugs: Excluded are medications considered to be 10. Custodial Care: Custodial care, domiciliary care, benefit exclusions by the Pennsylvania Children’s residential care, and protective and supportive care, Health Insurance Program (CHIP). These include including, but not limited to, respite care, rest cures, Drug Efficacy Study Implementation (DESI) drugs, experimental drugs, weight loss drugs, infertility

2 agents, and drugs used for cosmetic purposes. Also 19. Intellectual Disability: Services for treatment excluded are anabolic steroids, biologicals, blood or of intellectual disability except as otherwise blood plasma, drugs labeled for investigational use, provided herein. drugs used for hair growth, impotency drugs, and urine strips. There is no coverage for lost, stolen, 20. Long-Term Care: Care and related services in a long- or destroyed medications, or prescriptions that are term care facility. over-refilled or dispensed after one year. 21. Medically Unnecessary Services: Services or 13. Durable Medical Equipment: Medical equipment/ supplies which do not meet UPMC for Kids definition supplies that are a) of an expendable nature, e.g., of medically necessary and/or medical necessity disposable items such as incontinent pads, catheters, and appropriateness. The definition of medically irrigation kits, disposable electrodes, Ace bandages, necessary and appropriate (medical necessity and and elastic stockings; b) dressings unless the level appropriateness) is: of care requires skilled nursing care in the home; c) primarily used for non-medical purposes, e.g., air Services or supplies provided by a hospital, facility, conditioners, humidifiers, or electric air cleaners; other provider, professional provider, or professional and d) basically comfort or convenience items other provider that UPMC for Kids determines are: or are primarily for the convenience of a person a.) Appropriate for the symptoms and diagnosis caring for a member, e.g., exercise equipment, or treatment of the member’s condition, illness, stair glides, elevators, Hoyer Lifts, shower/ disease, or injury; and bath bench, orthopedic mattresses, or home or b.) Provided for the diagnosis or the direct care and automobile modifications, whether or not specifically treatment of the member’s condition, illness, recommended by a physician or other professional disease, or injury; and provider, unless specifically authorized by UPMC for Kids or its designee. c.) Provided in accordance with standards of good medical practice and consistent in type, 14. Experimental/Investigative: Procedures, frequency, and duration of treatment with technologies, treatments, equipment, drugs, and scientifically based guidelines from medical devices which are experimental/`investigative as research or health care coverage organizations determined by UPMC for Kids or that are used as or governmental agencies that are accepted by a necessary accompaniment to an experimental/ UPMC for Kids; and investigative procedure/service for phase 1 or phase d.) Not provided as a convenience. 2 clinical trials. Also excluded are experimental/ investigative drugs/therapy and services that are UPMC for Kids reserves the right to determine in its covered under the grant for phase 3 or phase 4 judgment whether a service is medically necessary clinical trials. and appropriate. No benefits hereunder will be provided unless UPMC for Kids determines that 15. Forms: Charges for completion of any specialized the service or supply is medically necessary and report, form, insurance form, or copying of appropriate. Authorization decisions shall be made medical records. by UPMC for Kids with input from the member’s PCP, or other physician providing service at the 16. Genetic Counseling Studies: Genetic counseling direction of the PCP, constituting proof of medical and studies that are not medically necessary for necessity for purposes of determining the member’s treatment of a defined medical condition. potential liability.

17. Home Care: Home care for chronic conditions 22. Military Service: Care for military service connected such as permanent, irreversible disease, injuries, or disabilities and conditions for which the member is congenital conditions requiring long periods of care legally entitled to services, and for which facilities are or observation. No coverage is provided for dietary reasonably accessible to the member. services, homemaker services, maintenance therapy, custodial care, and food or home-delivered meals. 23. Motor Vehicle Accident/Workers’ Compensation: The cost of hospital, medical, or other health services 18. Immunizations and Drugs: Immunizations and drugs resulting from accidental bodily injuries arising out of used for prevention of disease when required for a motor vehicle accident, to the extent such benefits employment or traveling outside of the United States.

3 are payable under any medical expense payment • Services related to purposes of obtaining or provision (by whatever terminology used — including maintaining a license, employment, or insurance, such benefits mandated by law) of any automobile or for purposes related to judicial or administrative insurance policy unless otherwise prohibited by proceedings, such as adjudication of marital, child applicable law. Service for which other coverage support, or custody cases. is required by federal, state, or local law to be • Services requiring a prior authorization by UPMC purchased or provided through other arrangements, for Kids for which the member or the treating including, but not limited to, coverage required provider did not obtain prior authorization. by workers’ compensation, no-fault automobile insurance, or similar legislation. • Services that are submitted by two different professional providers who provided the same 24. Non-covered Services: services on the same date for the same member. • Any services, supplies, or treatments not • Services which are primarily educational in nature, specifically listed as a covered benefit, service, vocational rehabilitation, and recreational and supply, or treatment under UPMC for Kids unless educational therapy. they are basic health services. Any services • Treatment of sexual dysfunction not directly related to or necessitated by an excluded item or related to organic disease or injury. non-covered service. • Charges for copayments which are the member’s 25. Non-Medical Items: Health club memberships, air responsibility. conditioners, televisions, telephones, dehumidifiers, air purifiers, food blenders, exercise equipment, • Charges for telephone conversations or failure to orthopedic mattresses, home or automobile keep a scheduled appointment. modifications, whirlpools, barber or beauty service, • Services and supplies that are not provided or guest service, or similar items, even if recommended arranged by a UPMC for Kids’ participating provider by a physician. and authorized for payment in accordance with UPMC for Kids’ medical management policies and 26. Nutritional Supplements: Food, food supplements, procedures. Services provided by a non-licensed special medical foods, other nutritional and over-the- practitioner or practitioner not recognized by counter electrolyte supplements, except as required UPMC for Kids. for the therapeutic treatment of phenylketonuria (PKU), branched-chain ketonuria, galactosemia, • Services incurred after the date of termination and homocystinuria, other rare hereditary genetic of the member’s coverage except as required by metabolic disorders, or as mandated by state law the Pennsylvania Children’s Health Insurance as administered under the direction of a physician. Program (CHIP). (Special medical foods are special foods and oral • Services provided before the member’s effective formulas designed to restrict intake of one or more date of coverage. specific nutrients such as amino acids, sugars, • Services rendered by a provider who is a member or fats.) of the member’s immediate family. Treatment or This includes: consultation provided by the member’s parents, • Any formulae, when used for the convenience of siblings, children, stepchildren, current or former the member or the member’s family. spouse or domiciliary partner, mother-in-law, father-in-law, sister-in-law, brother-in-law, or • Blenderized food, baby food, or regular shelf food grandparent. when used with an enteral system. (Shelf foods include baby food, food thickeners, or other regular • Services for which the member would have no grocery products that can be mixed in blenders legal obligation to pay. and are used with an enteral system regardless of • Services performed by a professional provider whether they are taken orally or parenterally.) enrolled in an education or training program when • Milk- or soy-based infant formulae with such services are related to the education or intact proteins. training program. • Normal food products used in the dietary management of rare hereditary genetic metabolic disorders.

4 • Nutritional supplements or any other substance 30. Pregnancy Termination Services: Pregnancy utilized for the sole purpose of weight loss or gain, termination services, except those provided for under or for caloric supplementation, limitation, the Commonwealth of Pennsylvania laws. or maintenance. 31. Private Duty Nursing: Private duty nursing services • Oral semisynthetic intact protein/protein isolates, are limited to a maximum of 16 hours per day. The natural intact protein/protein isolates, and intact use of private duty nursing is counted toward the protein/protein isolates. home health benefit and will not be covered in excess • Regular food products or shelf products, including of the maximum number of days allowed for home oral nutritional supplements that are available over health care per benefit period. the counter. 32. Public Facility/Government: Care for conditions that • Food supplements, lactose-free foods, vitamins federal, state, or local law requires to be treated in and/or minerals used to replace intolerable foods, a public facility or services furnished by any level of for lactose intolerance, or certain infant formulas government, unless coverage is legally required. (for example, Neocate, Nutramigen, and Elecare) to supplement a deficient diet or to provide 33. Rehabilitative Therapy: Rehabilitative therapy alternative nutrition. services, including, but not limited to, physical • Vitamins and/or minerals taken orally unless therapy, occupational therapy, and speech therapy, covered by the pharmacy benefit. for developmental delay, school-related problems, • Enteral products and related supplies that are apraxic disorders (not caused by accident or episodic administered orally. illness), stuttering, speech delay, articulation disorder, functional dysphonia, or speech problems resulting 27. Oral Surgery: Oral surgery related services, from psychoneurotic or personality disorders. including a) services required for correction of an occlusal defect, b) services which encompass 34. Sex Reassignment Services and Procedures. orthognathic or prognathic surgical procedures, and 35. Skilled Nursing: Inpatient days in a skilled nursing c) treatment of temporomandibular joint syndrome or facility in excess of the maximum number of days temporomandibular joint disorders, with the exception per benefit period when the primary reason for of surgery for temporomandibular joint disease. the admission is to receive skilled medical care, as 28. Physical Examinations: Physical examination indicated in the UPMC for Kids Summary of Benefits. or evaluation or any mental health or chemical Inpatient days in a skilled nursing facility that do dependency evaluation given primarily at the request not meet UPMC for Kids definition of skilled nursing of, for the protection or convenience of, or to meet a services/skilled rehabilitation services. Also, skilled requirement of a third party, including, but not limited nursing facility care is not covered for mental health to, attorneys, employers, insurers, schools, camps, treatment or the treatment of chemical abuse and driver’s license bureaus. or dependency. 29. Podiatry Services: Palliative or cosmetic foot 36. Sterilization Procedures and Reversal of care, including, but not limited to, a) treatment of Sterilization Procedures and Related Services. weak, strained, flat, unstable, or unbalanced feet; metatarsalgia or bunions (except open cutting 37. Surrogate Motherhood: All services and supplies procedures) and b) treatment of corns, calluses, associated with surrogate motherhood, including, but or toenails (except medically necessary surgery to not limited to, all services and supplies relating to the remove nail roots). Also excluded are a) supportive conception of prenatal through postnatal care of a orthotic devices for the foot, with the exception member acting as a surrogate mother. of devices required due to diabetes or peripheral vascular disease, and b) the use of extracorporeal shock waves for the treatment of plantar fasciitis and other similar conditions as these are considered experimental and investigative procedures.

5 38. Transplants/Organ Donation: Experimental or investigative transplants are not covered. Services required by a member related to organ donation when the member serves as the organ donor and benefits are available to the donor from any other source. Services required by a donor and benefits are available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program. Benefits provided to the donor will be charged against the member’s coverage. No payment will be made for human organs which are sold rather than donated.

39. Transportation: Routine or non-emergent transportation, by any means, unless authorized for payment in accordance with UPMC for Kids applicable policy and procedure.

40. Vision: The following are vision care exclusions: • Coverage for medical or surgical treatment, drugs or medications, non-prescription lenses, examinations, training procedures, or materials not listed as a UPMC for Kids benefit. • Procedures determined by UPMC for Kids to be special or unusual, such as, but not limited to, orthoptics, vision training, subnormal vision aids, and tonography. • Replacement of lost, stolen, broken or damaged lenses, contact lenses or frames, except at intervals specified in the UPMC for Kids Summary of Benefits. • Services or materials provided by federal, state, or local government or workers’ compensation. • Sunglasses (plain or prescription), industrial (3mm) safety lenses, and safety frames with side shields. • Surgery to correct myopia, hyperopia, astigmatism, and radial keratotomy.

41. Weight Reduction: Weight reduction programs, including all related diagnostic testing and other services. Bariatric surgery, anti-obesity medication, including, but not limited to, appetite suppressants and lipase inhibitors, are also excluded.

In this document, “member” is defined as an individual who has been determined to meet the eligibility requirements as established by the Pennsylvania Children’s Health Insurance Program (CHIP) and is enrolled in UPMC for Kids.

6 UPMC for Kids™ Exclusions for full-cost members

Not all services, supplies, or charges are Covered Services. • Inpatient or outpatient treatment related to Except as specifically provided in UPMC for Kids Summary intellectual disability, pervasive development of Benefits (located in the UPMC for Kids member disorder, or autism that extends beyond traditional handbook), no benefits will be provided for the following medical management. services, supplies, and charges, including, but not limited to: • Long-term residential treatment services for 1. Alternative Medicine: Including, but not limited substance-related disorders, such as substance to, acupuncture and acupressure, aromatherapy, abuse or substance dependency. aversion therapy, ayurvedic medicine, bioenergetic • Marriage or family counseling, except when therapy, carbon dioxide therapy, confrontation rendered in connection with services provided for therapy, crystal healing therapy, cult deprogramming, a treatable mental disorder (behavioral health or electric aversion therapy for alcoholism, expressive substance abuse). therapies such as art or psychodrama, guided imagery, herbal medicine, homeopathy, hyperbaric • Methadone maintenance for the treatment of therapy, massage therapy, narcotherapy, naturopathy, chemical dependency. orthomolecular therapy, primal therapy, relaxation • Psychiatric/psychological and neuro-psychological therapy, transcendental meditation and yoga, and testing for a) learning disabilities/problems, b) equestrian therapy. school-related issues, c) the purposes of obtaining or maintaining employment, d) purposes of 2. Assisted Fertilization: Artificial conception submitting a disability application for a mental processes such as, but not limited to, GIFT, ZIFT, or emotional condition, and e) any other testing embryo transplants, and in vitro fertilization. that does not require administration by a licensed behavioral health professional. 3. Behavioral Health Services: • Any service related to disorders that are not • Psychoanalysis or other therapies that are not treatable Diagnostic and Statistical Manual of short-term or crisis-oriented and do not relate to Mental Disorders (DSM) defined mental disorders treatable and defined mental disorders according according to the most recent version of DSM. to the most recent version of DSM. Examples include, but are not limited to, nicotine • Sensitivity training. dependence, caffeine intoxication, stuttering, • Treatment for personality disorders as the primary tension headache, stress reaction, reading disorder, diagnosis, learning disabilities, or behavioral mathematics disorder, pathological gambling, problems for those conditions. disorder of written expressions, expressive/ receptive language disorder, phonological disorder, • Treatment of organic disorders, including, but not developmental coordination disorder, learning limited to, organic brain disease. disorder, sleep disorder, sex therapy, and V-codes. • Treatment of chronic behavioral conditions once • Autism Spectrum Disorder: Please see the UPMC the individual has been restored to the pre-crisis for Kids’ Member Handbook for an explanation level of function. Coverage is provided until the of what services are covered for the diagnostic behavioral health condition is stable with no assessment and treatment of Autism Spectrum chance of improvement. Disorder. • Treatment of chronic pain management programs • Behavioral health services not expected to result or any related services under the behavioral health in demonstrable improvement in the member’s benefit when the primary diagnosis is pain. condition and/or level of function, and chronic • Treatment of stress, co-dependency, and sexual maintenance therapy, except in the case of serious addiction; sedative action electrostimulation mental illness/disorders. therapy. • Truancy or disciplinary problems alone.

7 • Twelve-step model programs as sole therapy for 9. Custodial Care: Custodial care, domiciliary care, problems, including, but not limited to, eating residential care, and protective and supportive care, disorders or addictive gambling. including, but not limited to: respite care, rest cures, • Vagus nerve stimulation for the treatment of educational services, convalescent care, dietary depressive disorders. services, homemaker services, maintenance therapy, and food or home-delivered meals. 4. Biofeedback Treatment: Biofeedback treatment for pediatric dysfunctional elimination is limited to 10. Dental Services: The following are dental care members from ages 5 to 18 with a maximum of 10 exclusions: visits per lifetime. • Cases involving covered services in which the dentist and member select a more expensive 5. Comfort/Convenience Items: Health club course of treatment than is customarily provided memberships, air conditioners, televisions, by the dental profession consistent with sound telephones, dehumidifiers, air purifiers, food professional standards of dental practice for the blenders, exercise equipment, orthopedic mattresses, dental condition concerned. Payment under UPMC home or automobile modifications, whirlpools, for Kids will be based on the provider-negotiated barber or beauty service, guest service, or similar fees under UPMC for Kids. items, even if recommended by a physician. • Duplicate and temporary devices, appliances, 6. Corrective Appliances: Corrective appliances and services. primarily intended for athletic purposes or those • Implantology and related services. related to a sports medicine treatment plan, and • Labial veneers and laminates done for cosmetic other appliances/devices, and any related services, purposes. However, if performed for restorative including, but not limited to, children’s corrective purposes, labial veneers and laminates are covered shoes, arch supports, special clothing or bandages under the same conditions and to the same extent of any type, back braces, lumbar corsets, hand that amalgam and composite restorations are splints, and shoe inserts and orthopedic shoes, covered. unless the shoe inserts or orthopedic shoes are required specifically due to diabetes or peripheral • Local anesthesia when billed for separately by vascular disease. a dentist. • Oral surgery which is performed under the medical 7. Cosmetic Surgery or Other Procedures: Cosmetic portion of benefits. surgery or other procedures to repair or reshape a body structure for the improvement of the person’s • Plaque control programs and oral hygiene and appearance or for psychological or emotional dietary instruction. reasons, and from which no improvement or • Procedures to alter vertical dimension and/or physiological function can be expected, except for restore or maintain the occlusion. Such procedures surgery or services which are required to be covered include, but are not limited to, equilibration, by law, including, but not limited to, removal, revision, periodontal splinting, full mouth rehabilitation, or reduction of port wine stains; augmentation restoration of tooth structure lost from attrition, procedures; reduction procedures (including male and restoration for malalignment of teeth. gynecomastia); scar revisions; or otoplasty. • Retainer replacement. 8. Court Ordered: Court-ordered services when not • Services covered under the medical portion of medically necessary for the member’s medical or UPMC for Kids benefits. behavioral health condition, as determined by the • Services submitted by a professional provider and member’s physician. a dentist that are the same services performed on the same dates for the same patient. • Treatment of temporomandibular joint syndrome (TMJ) with intra-oral devices or any other method to alter vertical dimension.

8 11. Drugs: Excluded are medications considered to be 16. Home Care: Home care for chronic conditions benefit exclusions by the Pennsylvania Children’s such as permanent, irreversible disease, injuries, or Health Insurance Program (CHIP). These include congenital conditions requiring long periods of care Drug Efficacy Study Implementation (DESI) drugs, or observation. No coverage is provided for dietary experimental drugs, weight loss drugs, infertility services, homemaker services, maintenance therapy, agents, and drugs used for cosmetic purposes. Also custodial care, and food or home-delivered meals. excluded are anabolic steroids, biologicals, blood or blood plasma; drugs labeled for investigational use, 17. Immunizations and Drugs: Immunizations and drugs drugs used for hair growth, impotency drugs, and used for prevention of disease when required for urine strips. There is no coverage for lost, stolen, employment or traveling outside of the United States. or destroyed medications; or prescriptions that are over-refilled or dispensed after one year. 18. Intellectual Disability: Services for treatment of intellectual disability except as otherwise 12. Durable Medical Equipment: Medical equipment/ provided herein. supplies that are a) of an expendable nature, e.g., disposable items such as incontinent pads, catheters, 19. Long-Term Care: Care and related services in a long- irrigation kits, disposable electrodes, Ace bandages, term care facility. and elastic stockings; b) dressings unless the level 20. Medically Unnecessary Services: Services or of care requires skilled nursing care in the home; c) supplies which do not meet UPMC for Kids definition primarily used for non-medical purposes, e.g., air of medically necessary and/or medical necessity conditioners, humidifiers, or electric air cleaners; and appropriateness. The definition of medically and d.) basically comfort or convenience items necessary and appropriate (medical necessity and or are primarily for the convenience of a person appropriateness) is: caring for a member, e.g., exercise equipment, stair glides, elevators, Hoyer Lifts, shower/ Services or supplies provided by a hospital, bath bench, orthopedic mattresses, or home or facility,other provider, professional provider, or automobile modifications, whether or not specifically professional other provider that UPMC for Kids recommended by a physician or other professional determines are: provider, unless specifically authorized by UPMC for a.) Appropriate for the symptoms and diagnosis Kids or its designee. or treatment of the member’s condition, illness, disease, or injury; and 13. Experimental/Investigative: Procedures, technologies, treatments, equipment, drugs, and b.) Provided for the diagnosis or the direct care and devices which are experimental/investigative as treatment of the member’s condition, illness, determined by UPMC for Kids or that are used as disease, or injury; and a necessary accompaniment to an experimental/ c.) Provided in accordance with standards of investigative procedure/service for phase 1 or phase good medical practice and consistent in type, 2 clinical trials. Also excluded are experimental/ frequency, and duration of treatment with investigative drugs/therapy and services that are scientifically based guidelines from medical covered under the grant for phase 3 or phase 4 research or health care coverage organizations clinical trials.* or governmental agencies that are accepted by UPMC for Kids; and 14. Forms: Charges for completion of any specialized report, form, insurance form, or copying of medical d.) Not provided as a convenience. records. UPMC for Kids reserves the right to determine in its 15. Genetic Counseling Studies: Genetic counseling judgment whether a service is medically necessary and studies that are not medically necessary for and appropriate. No benefits hereunder will be treatment of a defined medical condition. provided unless UPMC for Kids determines that the service or supply is medically necessary and appropriate. Authorization decisions shall be made by UPMC for Kids with input from the member’s PCP, or other physician providing service at the

* Exclusion may not apply to full-cost members. 9 direction of the PCP, constituting proof of medical • Services rendered by a provider who is a member necessity for purposes of determining the member’s of the member’s immediate family. Treatment or potential liability. consultation provided by the member’s parents, siblings, children, stepchildren, current or former 21. Military Service: Care for military service connected spouse or domiciliary partner, mother-in-law, disabilities and conditions for which the member is father-in-law, sister-in-law, brother-in-law, or legally entitled to services, and for which facilities are grandparent. reasonably accessible to the member. • Services for which the member would have no 22. Motor Vehicle Accident/Workers’ Compensation: legal obligation to pay. The cost of hospital, medical, or other health services • Services performed by a professional provider resulting from accidental bodily injuries arising out of enrolled in an education or training program when a motor vehicle accident, to the extent such benefits such services are related to the education or are payable under any medical expense payment training program. provision (by whatever terminology used — including • Services related to purposes of obtaining or such benefits mandated by law) of any automobile maintaining a license, employment, or insurance, insurance policy unless otherwise prohibited by or for purposes related to judicial or administrative applicable law. Service for which other coverage proceedings, such as adjudication of marital, child is required by federal, state, or local law to be support, or custody cases. purchased or provided through other arrangements, including, but not limited to, coverage required • Services requiring a prior authorization by UPMC by workers’ compensation, no-fault automobile for Kids for which the member or the treating insurance, or similar legislation. provider did not obtain prior authorization. • Services that are submitted by two different 23. Non-covered Services: professional providers who provided the same • Any services, supplies or treatments not services on the same date for the same member. specifically listed as a covered benefit, service, • Services which are primarily educational in nature, supply, or treatment under UPMC for Kids unless vocational rehabilitation, and recreational and they are basic health services. Any services educational therapy. related to or necessitated by an excluded item or non-covered service. • Treatment of sexual dysfunction not directly related to organic disease or injury. • Charges for copayments which are the member’s responsibility. 24. Non-Medical Items: Health club memberships, air • Charges for telephone conversations or failure to conditioners, televisions, telephones, dehumidifiers, keep a scheduled appointment. air purifiers, food blenders, exercise equipment, orthopedic mattresses, home or automobile • Services and supplies that are not provided or modifications, whirlpools, barber or beauty service, arranged by a UPMC for Kids’ participating provider guest service, or similar items, even if recommended and authorized for payment in accordance with by a physician. UPMC for Kids’ medical management policies and procedures. Services provided by a non-licensed 25. Nutritional Supplements: Food, food supplements, practitioner or practitioner not recognized by special medical foods, other nutritional and over-the- UPMC for Kids. counter electrolyte supplements, except as required • Services incurred after the date of termination for the therapeutic treatment of phenylketonuria of the member’s coverage except as required by (PKU), branched-chain ketonuria, galactosemia, the Pennsylvania Children’s Health Insurance and homocystinuria, other rare hereditary genetic Program (CHIP). metabolic disorders, or as mandated by state law as administered under the direction of a physician. • Services provided before the member’s effective (Special medical foods are special foods and oral date of coverage. formulas designed to restrict intake of one or more specific nutrients such as amino acids, sugars or fats.)

10 This includes: 28. Podiatry Services: Palliative or cosmetic foot • Any formulae, when used for the convenience of care, including, but not limited to, a) treatment of the member or the member’s family. weak, strained, flat, unstable, or unbalanced feet; metatarsalgia or bunions (except open cutting • Blenderized food, baby food, or regular shelf food procedures) and b) treatment of corns, calluses, when used with an enteral system. (Shelf foods or toenails (except medically necessary surgery to include baby food, food thickeners, or other regular remove nail roots). Also excluded are a) supportive grocery products that can be mixed in blenders orthotic devices for the foot, with the exception and are used with an enteral system regardless of of devices required due to diabetes or peripheral whether they are taken orally or parenterally.) vascular disease, and b) the use of extracorporeal • Milk- or soy-based infant formulae with intact shock waves for the treatment of plantar fasciitis proteins. and other similar conditions as these are considered • Normal food products used in the dietary experimental and investigative procedures. management of rare hereditary genetic metabolic 29. Pregnancy Termination Services: Pregnancy disorders. termination services, except those provided for under • Nutritional supplements or any other substance the Commonwealth of Pennsylvania laws. utilized for the sole purpose of weight loss or gain, or for caloric supplementation, limitation, or 30. Public Facility/Government: Care for conditions that maintenance. federal, state, or local law requires to be treated in a public facility or services furnished by any level of • Oral semisynthetic intact protein/protein isolates, government, unless coverage is legally required. natural intact protein/protein isolates, and intact protein/protein isolates. 31. Rehabilitative Therapy: Rehabilitative therapy • Regular food products or shelf products, including services, including, but not limited to, physical oral nutritional supplements that are available over therapy, occupational therapy, and speech therapy, the counter. for developmental delay, school-related problems, • Food supplements, lactose-free foods, vitamins apraxic disorders (not caused by accident or episodic and/or minerals used to replace intolerable foods, illness), stuttering, speech delay, articulation disorder, for lactose intolerance, or certain infant formulas functional dysphonia, or speech problems resulting (for example, Neocate, Nutramigen, and Elecare) from psychoneurotic or personality disorders. to supplement a deficient diet or to provide 32. Sex Reassignment Services and Procedures. alternative nutrition. • Vitamins and/or minerals taken orally unless 33. Skilled Nursing: Inpatient days in a skilled nursing covered by the pharmacy benefit. facility that do not meet UPMC for Kids definition of skilled nursing services/skilled rehabilitation services. • Enteral products and related supplies that are Also, skilled nursing facility care is not covered for administered orally. mental health treatment or the treatment of chemical 26. Oral Surgery: Oral surgery related services, abuse or dependency. including a) services required for correction of 34. Surrogate Motherhood: All services and supplies an occlusal defect, b) services which encompass associated with surrogate motherhood, including, but orthognathic or prognathic surgical procedures, and not limited to, all services and supplies relating to the c) treatment of temporomandibular joint syndrome or conception of prenatal through postnatal care of a temporomandibular joint disorders, with the exception member acting as a surrogate mother. of surgery for temporomandibular joint disease.

27. Physical Examinations: Physical examination or evaluation or any mental health or chemical dependency evaluation given primarily at the request of, for the protection or convenience of, or to meet a requirement of a third party, including, but not limited to, attorneys, employers, insurers, schools, camps, and driver’s license bureaus.

11 35. Transplants/Organ Donation: Experimental or 38. Weight Reduction: Weight reduction programs and investigative transplants are not covered. Services products not included in the Preventive Services required by a member related to organ donation Reference Guide. Weight reduction programs, when the member serves as the organ donor and including all related diagnostic testing and other benefits are available to the donor from any other services, except when such coverage is required source. Services required by a donor and benefits by the Affordable Care Act. Bariatric surgery, anti- are available to the donor from any other source. obesity medication, including, but not limited to, This includes, but is not limited to, other insurance appetite suppressants and lipase inhibitors. coverage or any government program. Benefits provided to the donor will be charged against the In this document, “member” is defined as an individual who member’s coverage. No payment will be made for has been determined to meet the eligibility requirements human organs which are sold rather than donated. as established by the Pennsylvania Children’s Health Insurance Program (CHIP) and is enrolled in UPMC for Kids. 36. Transportation: Routine or non-emergent transportation, by any means, unless authorized for payment in accordance with UPMC for Kids applicable policy and procedure.

37. Vision: The following are vision care exclusions: • Coverage for medical or surgical treatment, drugs or medications, non-prescription lenses, examinations, training procedures, or materials not listed as a UPMC for Kids benefit. • Procedures determined by UPMC for Kids to be special or unusual, such as, but not limited to: orthoptics, vision training, subnormal vision aids, and tonography. • Replacement of lost, stolen, broken or damaged lenses, contact lenses or frames, except at intervals specified in the UPMC for Kids Summary of Benefits. • Services or materials provided by federal, state, or local government or workers’ compensation. • Sunglasses (plain or prescription), industrial (3mm) safety lenses, and safety frames with side shields. • Surgery to correct myopia, hyperopia, astigmatism, and radial keratotomy.

1-800-650-8762 TTY users: 1-800-361-2629 www.upmchealthplan.com/members/forkids

This managed care plan may not cover all of your health care expenses.

Read all UPMC for Kids™ materials carefully to determine which health care services are covered.

U.S. Steel Tower, 600 Grant Street Pittsburgh, PA 15219 www.upmchealthplan.com/ members/forkids