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Exclusions and Limitations: What Is Not Covered by This Policy
Excluded Services
In addition to any other exclusions and limitations described in this Policy, there are no benefits
provided for the following:
1. Services obtained from a Non-Participating/Out-of-Network Provider, except for treatment
of an Emergency Medical Condition.
2. Any amounts in excess of maximum benefit limitations of Covered Expenses stated in this
Policy.
3. Services not specifically listed as Covered Services in this Policy.
4. Services or supplies that are not Medically Necessary.
5. Services or supplies that are considered to be for Experimental Procedures or
Investigational Procedures or Unproven Procedures.
6. Services received before the Effective Date of coverage.
7. Services received after coverage under this Policy ends.
8. Services for which you have no legal obligation to pay or for which no charge would be
made if you did not have a health plan or insurance coverage.
9. Any condition for which benefits are recovered or can be recovered, either by adjudication,
settlement or otherwise, under any workers’ compensation, employer’s liability law or
occupational disease law, even if the Insured Person does not claim those benefits.
10. Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release
of nuclear energy when government funds are available for treatment of Illness or Injury arising
from such release of nuclear energy; (c) an Insured Person participating in the military
service of any country; (d) an Insured Person participating in an insurrection, rebellion, or
riot; (e) services received as a direct result of an Insured Person’s commission of, or attempt
to commit a felony (whether or not charged) or as a direct result of the Insured Person being
engaged in an illegal occupation; (f) an Insured Person being intoxicated, as defined by
applicable state law in the state where the Illness occurred or under the influence of illegal
narcotics or non-prescribed controlled substances unless administered or prescribed by
Physician.
11. Any services provided by a local, state or federal government agency, except when
payment under this Policy is expressly required by federal or state law.
12. Any services required by state or federal law to be supplied by a public school system or school
district.
13. Any services for which payment may be obtained from any local, state or federal
government agency (except Medicaid). Veterans Administration Hospitals and military
treatment facilities will be considered for payment according to current legislation.
14. If the Insured Person is enrolled in Medicare Part A, B, C or D, Cigna Healthcare will provide
claim payment according to this Policy minus any amount paid by Medicare, not to exceed the
amount Cigna Healthcare would have paid if it were the sole insurance carrier.
15. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a
Physician and listed as covered in this Policy.
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16. Professional services or supplies received or purchased directly or on your behalf by
anyone, including a Physician, from any of the following:
o Yourself or your employer;
o A person who lives in the Insured Person’s home, or that person’s employer;
o A person who is related to the Insured Person by blood, marriage or adoption, or that
person’s employer; or
o A facility or health care professional that provides remuneration to you, directly or
indirectly, or to an organization from which you receive, directly or indirectly, remuneration.
17. Services of a Hospital emergency room for any condition that is not an Emergency Medical
Condition as defined in this Policy.
18. Custodial Care, including but not limited to rest cures; infant, child or adult day care,
including geriatric day care.
19. Private duty nursing except when provided as part of the home health care services benefit in
this Policy.
20. Inpatient room and board charges in connection with a Hospital stay primarily for
environmental change or Physical Therapy.
21. Services received during an inpatient stay when the stay is primarily related to behavioral,
social maladjustment, lack of discipline or other antisocial actions which are not specifically
the result of a Mental Health Disorder.
22. Complementary and alternative medicine services, including but not limited to: massage
therapy; animal therapy, including but not limited to equine therapy or canine therapy; art
therapy; meditation; visualization; acupuncture; acupressure; acupuncture point injection
therapy; reflexology; rolfing; light therapy; aromatherapy; music or sound therapy; dance
therapy; sleep therapy; hypnosis; energy-balancing; breathing exercises; movement and/or
exercise therapy including but not limited to yoga, pilates, tai-chi, walking, hiking, swimming,
golf; and any other alternative treatment as defined by the National Center for Complementary
and Alternative Medicine (NCCAM) of the National Institutes of Health. Services specifically
listed as covered under “Rehabilitative Therapy” and “Habilitative Therapy” are not subject to
this exclusion.
23. Any services or supplies provided by or at a place for the aged, a nursing home, or any
facility a significant portion of the activities of which include rest, recreation, leisure, or any
other services that are not Covered Services.
24. Assistance in activities of daily living, including but not limited to: bathing, eating, dressing,
or other Custodial Care, self-care activities or homemaker services, and services primarily for
rest, domiciliary or convalescent care.
25. Services performed by unlicensed practitioners or services which do not require licensure
to perform, for example meditation, breathing exercises, guided visualization.
26. Inpatient room and board charges in connection with a Hospital stay primarily for
diagnostic tests which could have been performed safely on an outpatient basis.
27. Services which are self-directed to a free-standing or Hospital-based diagnostic facility.
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28. Services ordered by a Physician or other Provider who is an employee or representative
of a free-standing or Hospital-based diagnostic facility, when that Physician or other
Provider:
o Has not been actively involved in your medical care prior to ordering the service, or
o Is not actively involved in your medical care after the service is received.
This exclusion does not apply to mammography.
29. Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of
teeth or treatment to the teeth or gums, except as specifically provided in this Policy.
30. Orthodontic services, braces and other orthodontic appliances including orthodontic services
for Temporomandibular Joint Dysfunction.
31. Dental implants: dental materials implanted into or on bone or soft tissue or any associated
procedure as part of the implantation or removal of dental implants.
32. Any services covered under both this medical plan and an accompanying exchange-
certified pediatric dental plan and reimbursed under the dental plan will not be reimbursed
under this plan.
33. Hearing aids including but not limited to semi-implantable hearing devices, audiant bone
conductors and Bone Anchored Hearing Aids (BAHAs), except as specifically stated in this
Policy, limited to the least expensive professionally adequate device. For the purposes of this
exclusion, a hearing aid is any device that amplifies sound.
34. Routine hearing tests except as provided under Preventive Care.
35. Gene Therapy including, but not limited to, the cost of the Gene Therapy product, and any
medical, surgical, professional and facility services directly related to the administration of the
Gene Therapy product.
36. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine
eye exams, and routine eye refractions, except as specifically stated in this Policy under
Pediatric Vision Care.
37. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as
nearsightedness (myopia), astigmatism and/or farsightedness (presbyopia).
38. Cosmetic surgery, therapy or other services for beautification, to improve or alter appearance
or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance.
This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct
a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary
Reconstructive Surgery performed to restore symmetry incident to a mastectomy or
lumpectomy.
39. Aids or devices that assist with nonverbal communication, including but not limited to
communication boards, prerecorded speech devices, laptop computers, desktop computers,
personal digital assistants (PDAs), braille typewriters, visual alert systems for the deaf and
memory books except as specifically stated in this Policy.
40. Non-medical counseling or ancillary services, including but not limited to: education,
training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, employment
counseling, back school, return to work services, work hardening programs, driving safety, and
services, training, educational therapy or other non-medical ancillary services for learning
disabilities and developmental delays, except as otherwise stated in this Policy.
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41. Services and procedures for redundant skin surgery including
abdominoplasty/panniculectomy, removal of skin tags, craniosacral/cranial therapy, applied
kinesiology, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal
and orthopedic conditions, macromastia or gynecomastia; varicose veins; rhinoplasty,
blepharoplasty and orthognathic surgeries.
42. Procedures, surgery or treatments to change characteristics of the body to those of the
opposite sex unless such services are deemed Medically Necessary or otherwise meet
applicable coverage requirements.
43. Any treatment, Prescription Drug, service or supply to treat sexual dysfunction, enhance
sexual performance or increase sexual desire.
44. All services related to the treatment of fertility and/or Infertility, including, but not limited to,
all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical
procedures including sterilization reversals and in vitro fertilization, gamete intrafallopian
transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this Policy.
45. Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including
donor fees).
46. Fees associated with the collection or donation of blood or blood products, except for
autologous donation in anticipation of scheduled services where in the utilization review
Physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected
adjunct to surgery.
47. Blood administration for the purpose of general improvement in physical condition.
48. Orthopedic shoes (except when joined to Braces), shoe inserts, foot Orthotic Devices.
49. External and internal power enhancements or power controls for Prosthetic limbs and
terminal devices.
50. Myoelectric Prostheses peripheral nerve stimulators.
51. Electronic Prosthetic limbs or appliances unless Medically Necessary, when a less-costly
alternative is not sufficient.
52. Prefabricated foot Orthoses.
53. Cranial banding/cranial Orthoses/other similar devices, except when used
postoperatively for synostotic plagiocephaly.
54. Orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications
and transfers.
55. Orthoses primarily used for cosmetic rather than functional reasons.
56. Non-foot Orthoses, except only the following non-foot Orthoses are covered when Medically
Necessary:
o Rigid and semi-rigid custom fabricated Orthoses;
o Semi-rigid pre-fabricated and flexible Orthoses; and
o Rigid pre-fabricated Orthoses, including preparation, fitting and basic additions, such as
bars and joints.
57. Services primarily for weight reduction or treatment of obesity including morbid obesity,
or any care which involves weight reduction as a main method for treatment. This includes any
morbid obesity surgery, even if the Insured Person has other health conditions that might be
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helped by a reduction of obesity or weight, or any program, product or medical treatment for
weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
58. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition.
This includes reports, evaluations, or hospitalization not required for health reasons; physical
exams required for or by an employer or for school, or sports physicals, or for insurance or
government authority, and court ordered, forensic, or custodial evaluation
s, except as
otherwise specifically stated in this Policy.
59. Therapy or treatment intended primarily to improve or maintain general physical condition
or for the purpose of enhancing job, school, athletic or recreational performance, including but
not limited to routine, long term, or maintenance care which is provided after the resolution of
the acute medical problem and when significant therapeutic improvement is not expected.
60. Educational services except for Diabetic Self-Management Training Programs, treatment for
Autism, or as specifically provided or arranged by Cigna Healthcare.
61. Nutritional counseling or food supplements, except as stated in this Policy.
62. Exercise equipment, comfort items and other medical supplies and equipment not
specifically listed as Covered Services in the “Comprehensive Benefits: What the Policy Pays
For” section of this Policy. Excluded medical equipment includes, but is not limited to: air
purifiers, air conditioners, humidifiers; treadmills; spas; elevators; supplies for comfort, hygiene
or beautification; disposable sheaths and supplies; correction appliances or support appliances
and supplies such as stockings, and consumable medical supplies other than ostomy supplies
and urinary catheters, including, but not limited to, bandages and other disposable medical
supplies, skin preparations and test strips except as otherwise stated in this Policy.
63. Physical, and/or Occupational Therapy/Medicine except when provided during an inpatient
Hospital confinement or as specifically stated in the benefit schedule and under “Rehabilitative
Therapy Services (Physical Therapy, Occupational Therapy and Speech Therapy)” in the
section of this Policy titled “Comprehensive Benefits: What the Policy Pays For.”
64. Foreign Country Provider charges except as specifically stated under “Foreign Country
Providers” in the section of this Policy titled “Comprehensive Benefits: What the Policy Pays
For.”
65. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails,
routine hygienic care and any service rendered in the absence of localized Illness, a systemic
condition, Injury or symptoms involving the feet except as otherwise stated in this Policy.
66. Charges for which We are unable to determine Our liability because the Insured Person
failed, within 60 days, or as soon as reasonably possible to: (a) authorize Us to receive all the
medical records and information We requested; or (b) provide Us with information We requested
regarding the circumstances of the claim or other insurance coverage.
67. Charges for the services of a standby Physician.
68. Charges for animal to human organ transplants.
69. Claims received by Cigna Healthcare after 15 months from the date service was rendered,
except in the event of a legal incapacity.
70. Services obtained from a Dedicated Virtual Care Physician that are not Dedicated Virtual
Urgent Care or Dedicated Virtual Primary Care services.
71. Abortions, except in cases of rape, incest, lethal fetal anomaly, or when the pregnant person’s
life faces a serious health risk.
