Covered Expenses will not include, and no payment will be made for, expenses incurred:
Physicians and other health professionals
- For routine physical examinations not required for health reasons including, but not limited to, employment, insurance, government license, court-ordered, forensic or custodial evaluations.
- Unless otherwise covered as a basic benefit, 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.
- For which benefits are not payable according to the General limitations section; except that the following will not apply to this section: (a) limitations with respect to a maximum for multiple surgical procedures, an allowable charge for an assistant surgeon or co-surgeon and covered providers being family members; (b) the limitation, if any, with respect to a child under 15 days old; and (c) any certification or second opinion requirements shown in the In-Network Benefits Schedule.
Hospital and other facility care
- Care for health conditions, which are required by state or local law to be treated in a public facility.
- Assistance in the activities of daily living, including, but not limited to eating, bathing, dressing, or other custodial or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.
- For court ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed under the Covered expenses section of this booklet.
- For non-medical ancillary services, including but not limited to vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back to school, work hardening, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning, intellectual or developmental disabilities.
- For private Hospital rooms and/or private duty nursing unless determined by Cigna to be Medically Necessary
- For 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.
- Autism Spectrum Disorder - Applied Behavior Analysis (ABA) will be covered consistent with Cigna’s clinical policy bulletins. Coverage does not include services for custodial care, educational services, or services performed in an academic, vocational or recreational setting.
- Mental health and substance use disorder services exclusions: any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under this plan.
- For Treatment/surgery of mandibular or maxillary prognathism, microprognathism or malocclusion, surgical augmentation for orthodontics, or maxillary constriction.
- For or in connection with treatment of the teeth or periodontium unless such expenses are incurred for: (a) charges made for a continuous course of Dental treatment started within six months of an Injury to sound natural teeth; or (b) charges made by a Hospital for Bed and Board or Necessary Services and Supplies; or (c) charges made by a Free-Standing Surgical Facility or the outpatient department of a Hospital in connection with surgery.
- For craniosacral therapy, panniculectomy and abdominoplasty, or prolotherapy.
- For temporomandibular joint dysfunction services.
- For bariatric surgery.
- For varicose vein treatment except when medically necessary.
- For in connection with procedures to reverse sterilization.
- For non-therapeutic or elective abortions.
- For rhinoplasty.
Specific therapies and tests
- For rehabilitative therapy by a licensed physical, occupational or speech therapist, or chiropractor, on an outpatient basis, limited to 60 days per Contract Year for any combination of these therapies but only if significant improvement can be expected as determined by the Cigna Medical Director. The maximum day limit for Rehabilitative Therapy does not apply to occupational therapy, physical therapy or speech therapy prescribed for the treatment of covered mental health conditions, including Autism Spectrum Disorder, Down syndrome, cerebral palsy, fetal alcohol syndrome, muscular dystrophy, and other covered developmental delays.
- For therapy to improve general physical condition if not Medically Necessary, including, but not limited to, routine, long-term chiropractic care, and rehabilitative services which are provided to reduce potential risk factors in patients in which significant therapeutic improvement is not expected.
- For amniocentesis, ultrasound, or any other procedures requested solely for gender determination of a fetus, unless Medically Necessary to determine the existence of a gender -linked genetic disorder.
- For genetic testing and therapy including germ line and somatic unless determined Medically Necessary by Cigna for the purpose of making treatment decisions.
- For Cosmetic Surgery or Therapy. Cosmetic Surgery or Therapy is defined as surgery or therapy performed to improve appearance or self-esteem, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary.
- Any services, except Emergencies, not provided upon the prior written approval of the Cigna Medical Director or rendered by Participating Providers.
- For hearing aids or examinations for prescription or fitting thereof, except as otherwise specified in this section.
- Services primarily of an educational nature or in an educational setting, including but not limited to services for developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.
- Respite, shadow, or companion services.
- Any program or service performed in a nonconventional setting, even if the services are performed by a licensed provider, including: spas/resorts, outdoor learning or leadership programs; academic, vocational, or recreational settings.
- Counseling for borderline intellectual functioning.
- Counseling for occupational problems.
- Counseling related to consciousness raising.
- Vocational or religious counseling.
- I.Q. testing.
- Custodial care, including but not limited to geriatric day care.
- Psychological testing on children requested by or for a school system.
- Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline.
- For replacement of external prostheses due to wear and tear resulting from misuse or abuse, loss, theft or destruction; or for any biomechanical external prosthetic devices.
- For penile prostheses, unless Medically Necessary.
- For the following vision care service, by way of example, but not of limitation: services or items related to orthoptics or vision training; magnification vision aids; charges for tinting, antireflective coatings, prescription sunglasses or light sensitive lenses; an eye examination required by an employer as a condition of employment or which an employer is required to provide under a collective-bargaining agreement; any eye exam required by law; safety glasses or lenses required for employment; any non-prescription eyeglasses, lenses or contact lenses.
- The limitation with respect to routine eye refraction's in the General limitations section will not apply to coverage for complete eye examinations.
- For treatment by acupuncture.
- For artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, hearing aids, dentures and wigs.
- For 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 Services" or "Breast Reconstruction and Breast Prostheses" sections of Covered expenses.
- For membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
- For fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in Cigna’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
- For blood administration for the purpose of general improvement in physical condition.
- For the cost of biologicals that are immunizations or medications for the purpose of the travel, or to protect against occupational hazards and risks.
- For cosmetics, dietary supplements, health and beauty aids and nutritional formulae. However, nutritional formulae for infants (less than one year of age) are covered when required for:
(a) the treatment of inborn errors of metabolism or inherited metabolic disease (including disorders of amino acid and organic acid metabolism); or
(b) enteral feeding for which the nutritional formulae under state or federal law can be dispensed only through a Physician's prescription, and are Medically Necessary as the primary source of nutrition.
- For all noninjectable prescription drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Covered expenses section of this booklet.
- For which benefits are not payable according to the General limitations section.
- Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law.