Exclusions and Limitations

Note: PacifiCare changed its name to UHC of California and will do business as (dba) UnitedHealthcare of California, effective May 2011. (See the March 25, 2011 announcement.)

Services and benefits for care and conditions as described below shall be excluded from coverage under this plan unless specifically included as a supplemental benefit.

General Exclusions

The following services are not covered by PacifiCare:

1. All services not specifically included in the Schedule of Benefits.
   


2. All services which are rendered without authorization from Member’s Primary Care Physician in Member’s Participating Medical Group (except for Emergency or Urgently Needed Services, or obstetrical and gynecological physician services obtained directly from an OB/GYN or Family Practice Physician (designated by your Participating Medical Group as providing OB/GYN services) affiliated with your Participating Medical Group).
   


3. Any services rendered prior to Member’s start date of coverage or subsequent to the date coverage ends.
   


4. Services rendered by Outside Providers when the Member has refused treatment provided or authorized through Member’s Primary Care Physician in Member’s participating Medical Group.
   


5. Services which, in the judgment of PacifiCare, are not Medically Necessary
   


6. Services which are part of a plan of treatment for a non-Covered service, which are the sole, direct and predictable consequences of such non-Covered Service as recognized by the organized medical community in the State of California; provided, however, that the Health Plan shall not exclude coverage for Medically Necessary services required to treat medical conditions that may be a consequence of non-Covered Services but are not predictable in advance, such as unexpected complications of surgery.

Other Exclusions and Limitations

Acupuncture, Acupressure, Biofeedback
Acupuncture, acupressure and biofeedback are not covered.

Alcoholism, Drug Addiction or Other Substance Abuse
Rehabilitation for chronic alcoholism, drug addiction or other substance abuse is not covered.

Ambulance Services
Ambulance services are not covered except when received as a Medically Necessary Emergency Service as described in the PacifiCare Membership Handbook or when specifically authorized by Member’s Primary Care Physician in Member’s Participating Medical Group.

Bone Marrow Transplants
Bone marrow transplants are not covered when they are Experimental or Investigational, unless required by an external, independent review panel pursuant to California Health and Safety Code Section 1370.4.

Cosmetic Surgery or Reconstructive Surgery
Cosmetic surgery is surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.  Cosmetic or reconstructive service exclusions determined in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, include but are not limited to:

1. A proposed surgery when there is another more appropriate surgical procedure that has been offered to the member.


2. Services that offer only a minimal improvement in the member’s appearance; or


3. Services performed without prior authorization by the Participating Medical Group.

When services are determined to be cosmetic, all services to be provided as part of the cosmetic treatment plan are also excluded, including, hospital, physician, medical supplies or medications (injectable, intravenous or taken by mouth).

Custodial Care
Custodial Care is not covered.  Custodial Care includes all homemaker services, respite care, convalescent care or extended care not requiring skilled nursing.

Dental Care, Dental Appliances
Dental Care is not covered.  Dental care includes all services required for prevention and treatment of diseases and disorders of the teeth, including but not limited to: oral exams, X-rays, routine fluoride treatment, plaque removal, tooth decay, dental embryonal tissue disorders, periodontal disease, anesthesia, repair and restoration, tooth extraction, replacement of missing teeth, dental implants, dentures and other oral prosthetic devices.

Developmental Disorders
Services that are primarily oriented toward treating a social, developmental or learning problem rather than a medical problem, including autism, dyslexia and behavioral modification therapy are not covered.

Disabilities Connected to Military Services
Treatment for disabilities connected to military service for which a Member is legally entitled to services through a federal governmental agency, and to which Member has reasonable access, are not covered.

Drugs and Prescription Medication
Prescribed and non-prescribed medications are not covered except when provided in an inpatient setting.  Notwithstanding the foregoing, injectable drugs are covered (except for insulin and insulin-related drugs and immunizations not covered under the immunization benefit) when they are administered during the course of a physician’s office visit or self-administered pursuant to training by an appropriate health care professional.

Durable Medical Equipment, Corrective Appliances and Prosthetics
Replacement of lost durable medical equipment, corrective appliances or prosthetics is not covered.  Additional optional accessories to durable medical equipment, corrective appliances or prosthetics that are primarily for the comfort or convenience of the Member, including home and car remodeling or modification, are not covered.  Prosthetics that requires surgical connection to nerves, muscles or other tissues (bionic) are not covered.  Prosthetics that have electric motors to enhance motion (myoelectronic) are not covered.

Emergency and Urgently Needed Services
Emergency and Urgently Needed Services are covered in a non-contracting facility only as long as the emergent or urgent condition exists and a transfer would be medically inappropriate.  Routine follow-up care including treatments, procedures, X-rays, lab work, physician visits, rehabilitation and Skilled Nursing Care will not be covered without the Participating Medical Group’s authorization once it is medically reasonable for the Member to obtain these services from the Participating Medical Group.  The fact that the Member is outside the Service Area and that it is inconvenient for the Member to obtain the required services from the Participating Medical Group will not entitle the Member to coverage.

Experimental or Investigational Treatment
Experimental or Investigational treatments are not covered unless required by an external, independent review panel pursuant to California Health and Safety Code Section 1370.4. Unless otherwise dictated by federal or state law, decisions as to whether a particular treatment is Experimental or Investigational, and therefore not a covered benefit, are determined by PacifiCare’s Medical Director or his or her designee based upon criteria established by PacifiCare’s Technology Assessment Committee pursuant to the following guidelines.

Any drug, device, treatment or procedure shall be deemed an Experimental or Investigational treatment if, as determined solely by PacifiCare, any one or more of the following criteria are met:

It cannot be lawfully marketed without the approval of the United States Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use;

It is the subject of a current investigational new-drug or new-device application on file with the FDA;

It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of the Phase III clinical trial, as these Phases or defined in regulations and other official actions and publications issued by the FDA and the Department of Health and Human Services (HHS);

It is being provided pursuant to a written protocol, which describes among its objectives determinations of safety and/or efficacy as compared with the standard means of treatment;

It is being delivered or should be delivered subject to the approval and supervision of an institutional Review Board (IRB) as required and defined by federal regulations and other official actions and publications issued by the FDA and the HHS;

The predominant opinion among experts as expressed in the published authoritative literature is that usage should be substantially confined to research settings;

The predominant opinion among experts as expressed in the published authoritative literature is that further research is necessary in order to define safety, toxicity, effectiveness or effectiveness compared with conventional alternatives; or

It is not Investigational or Experimental in itself pursuant to the above, and would not be Medically Necessary, but for the provision of a drug, device, treatment or procedure which is Investigational or Experimental.

The exclusive sources of information to be relied upon by PacifiCare in determining whether a particular treatment is Experimental or Investigational, and therefore not a covered benefit under this Agreement are limited to the following:

The Member’s medical records;

The protocol(s) pursuant to which the drug, device, treatment or procedure is to be delivered;

Any consent document the Member, or his or other representative, has executed or will be asked to execute, in order to receive the drug, device, treatment or procedure;

The published authoritative medical or scientific literature regarding the drug, device, treatment or procedure at issue as applied to the Medical Condition at issue;

Opinions of other agency review organizations/review organizations, e.g., ECRI Health Technology Assessment Information Service, HAYES New Technology Summaries or AHCPR (Agency for Health Care Policy and research);

Expert medical opinion;

Regulations and other official actions and publications issued by the FDA and HHS.

A terminally ill Member may be entitled to an expedited hearing in cases in which a proposed treatment is denied as Experimental or Investigational, as provided in the Subscriber Agreement or pursuant to California Health and Safety Code Section 1370.4.

Family Planning
Family Planning. Progesterone implants (Norplant) are limited to one device per 5-year period. Depo-Provera Medication is limited to one injection every ninety (90) days.

Foot Care
Routine foot care including, but not limited to, removal or reduction of corns and calluses, clipping of toenails, treatment for flat feet, fallen arches and chronic foot strain is not covered, except as PacifiCare determines is Medically Necessary.  Also note exclusions for Specialized Footwear.

Hearing Aids and Implantable Hearing Devices
Audiology services (other than screening for acuity) are not covered.  Hearing aids and supplies and other implantable hearing devices are not covered except for cochlear devices for bilateral, profoundly hearing-impaired individuals not benefiting from conventional amplification (hearing aids).

Infertility Reversal
Reversal of voluntary sterilization is not covered.

Infertility Services
Ovum transplants, ovum or ovum bank charges, sperm or sperm bank charges, and the Medical Services incurred by surrogate mothers who are not PacifiCare members are not covered. Medical or Hospital Services following reversal of elective sterilization, including medications and supplies, are not covered.  In-Vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT), as well as procedures related to IVF, GIFT and ZIFT are not covered.

Institution Services and Supplies - Non-Eligible
Any services or supplies furnished by a non-eligible institution, which is defined as an institution other than a legally operated hospital or Medicare-approved Skilled Nursing Facility or which is primarily a place of rest, a place for the aged, a nursing home or any similar institution, regardless of how denominated, are not covered.

Medicare Benefits for Medicare Retirees
The amount payable by Medicare for Medicare-covered services received by Medicare retirees, regardless of whether a Medicare retiree has enrolled in Medicare Part A and Part B, is not covered.

Mental Disorders (Crisis Intervention Only)
Mental Health services are not covered except for Crisis Intervention.  Crisis Intervention is defined as short-term Medically Necessary treatment required when Member suffers a sudden mental condition, which interferes with the Member’s daily activities and from which Member is incapable of recovering without assistance, in which case coverage is limited to twenty (20) outpatient visits per calendar year.

Non-Licensed Professionals
Treatment for any illness or injury when not attended by a licensed physician, surgeon or health care professional is not covered.

Nursing - Private Duty
Private duty nursing is not covered, unless determined to be Medically Necessary and ordered by Member’s Participating Medical Group and approved by the PacifiCare Medical Director.

Nutritional Supplement Formulas
Phenylketonuria (PKU) formula is covered through age eighteen (18) or during pregnancy.

Organ Donor Services
Medical and Hospital Services and other costs of a donor or prospective donor are not covered when the recipient is not a Member.

Organ Transplants
Organ transplants not Medically Necessary and organ transplants considered Experimental or Investigational as defined herein are not covered unless required by an external, independent review panel pursuant to California Health and Safety Code Section 1370.4.  The following organ transplants are examples of Experimental or Investigational at the time of printing this brochure: Pancreas (alone) transplant or pancreas after kidney transplant.

Out-of-Area Services
Medical and Hospital Services, except for Emergency and Urgently Needed Services, are not covered when received outside of the Service Area.  Out-of-Area follow-up care and maintenance therapy is not covered unless pre-approved by the PacifiCare Out-of-Area Unit or Member’s Participating Medical Group.  Out-of-Area follow-up care includes, but is not limited to:

• Routine follow-up care to Emergency or Urgently Needed Services, such as treatments, procedures, X-rays, lab work and doctor’s visits, as well as Rehabilitation Services, Skilled Nursing Care, Custodial Care or home care.


• Maintenance therapy and Durable Medical Equipment to assist a Member while traveling outside the Service Area including, but not limited to, routine dialysis, routine oxygen or a wheelchair, is not covered.

Physical Examinations
Routine physical examinations for insurance, licensing, employment, school, and camp, recreational or organizational activities are not covered.  Physical examinations for appearances at hearing for court proceedings, examinations precedent to engaging in travel, or other non-preventive purposes or for pre-marital and pre-adoption purposes are not covered.

Private Rooms and Comfort Items
Personal or comfort items and private rooms during inpatient hospitalization are not covered unless Medically Necessary.

Public Facility Care
Care of conditions for which state or local law requires treatment in a public facility are not covered.  However, PacifiCare will reimburse Member for out-of-pocket expenses incurred by the Member for any Covered Services delivered at such public facility.  Injuries or illnesses sustained while incarcerated in a state or federal prison are not covered.  Emergency and Urgently Needed Services required after participating in a criminal act are covered only until Member is stabilized and placed on a police hold.  Notwithstanding the foregoing, in compliance with Health and Safety Code section 1374.12, nothing in this provision shall be deemed to restrict the liability of PacifiCare with respect to Covered Services solely because such services were provided while the Member was in a state hospital.

Recreational, Educational or Hypnotic Therapy
Recreational, educational or hypnotic therapy and any related diagnostic testing is not covered except as provided as part of an otherwise covered inpatient hospitalization.

Sex Transformations
Procedures, services, medications and supplies related to sex transformations are not covered.

Skilled Nursing Facility Care
Skilled Nursing Facility (Medicare-certified) room and board charges incurred beyond one hundred (100) consecutive days per qualifying condition are not covered.  A qualifying condition is a medical condition which requires skilled nursing services, which as a practical matter, in the determination of PacifiCare and the Member’s Participating Medical Group, cannot be delivered in a setting other than a Hospital or a Skilled Nursing Facility, except that a medical condition will not be considered a qualifying condition if during the sixty (60) days preceding the medical condition the Member has received Skilled Nursing Care.

Specialized Footwear for Foot Disfigurement
Specialized footwear, including foot orthotics, custom-made standard orthopedic shoes, or customized footwear, which is not permanently attached to an orthopedic brace, is not covered.

Vision Care
Corrective lenses and frames, contact lenses (except post cataract extraction, keratoconus, aphakic or corneal bandages), contact lens fitting and measurements are not covered.

Weight Alteration Programs (Inpatient or Outpatient)
Weight loss or weight gain programs including, but not limited to, dietary evaluations and counseling, exercise programs, behavioral modification programs, surgery, laboratory tests, food and food supplements, vitamins and other nutritional supplements associated with weight loss or weight gain, are not covered.  Surgical treatment for morbid obesity will be covered only when criteria are met as recommended by the National Institute of Health (NIH).  Phenylketonuria (PKU) formula is covered through age eighteen (18) or during pregnancy.