LIMITATIONS/EXCLUSIONS (WHAT IS NOT COVERED)

Excluded Services

In addition to any other exclusions and limitations described in this Policy, there are no benefits provided for

the following:

 Services obtained from a Non-Participating/Out-of-Network Provider, except for treatment of an

Emergency Medical Condition.

 Any amounts in excess of maximum benefit limitations of Covered Expenses stated in this Policy.

 Services not specifically listed as Covered Services in this Policy.

 Services or supplies that are not Medically Necessary.

 Services or supplies that are considered to be for Experimental Procedures or Investigational Procedures

or Unproven Procedures.

 Services received before the Effective Date of coverage.

 Services received after coverage under this Policy ends.

 Services for which you have no legal obligation to pay or for which no charge would be made if you did

not have health plan or insurance coverage.

 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.

 Conditions caused by: (a) an act of war (declared or un-declared); (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, unless it occurred during a community protest;

(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.

 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.

 Any services required by state or federal law to be supplied by a public school system or school district.

 Any services for which payment may be obtained from any local, state or federal government agency

(except Medicaid or medical assistance benefits under the Colorado Medical Assistance Act, Title 25.5,

Articles 4, 5, and 6, C.R.S.). Veterans Administration Hospitals and military treatment facilities will be

considered for payment according to current legislation.

 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.

 Court-ordered treatment or hospitalization, unless such treatment is medically necessary and listed as

covered in this Policy.

 Professional services or supplies received or purchased from Yourself or 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.

 Services of a Hospital emergency room for any condition that is not an Emergency Medical Condition as

defined in this Policy.

 Custodial Care, including but not limited to rest cures; infant, child or adult day care, including geriatric

day care.

 Private duty nursing except when provided as part of the Home Health Care Services or Hospice Care

Services benefit in this Policy or as specifically stated in the section of this Policy titled

“Benefits/Coverage (What is Covered).”

 Inpatient room and board charges in connection with a Hospital stay primarily for environmental change

or Physical Therapy.

 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 Mental

Health Disorder.

 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; 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.

 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.

 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.

 Services performed by unlicensed practitioners or services which do not require licensure to perform, for

example mediation, breathing exercises, guided visualization.

 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.

 Services which are self-directed to a free-standing or Hospital based diagnostic facility.

 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.

 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.

 Orthodontic services, braces and other orthodontic appliances including orthodontic services for

Temporomandibular Joint Dysfunction , except for treatment for medically necessary orthodontia for a

person born with a cleft lip or cleft palate.

 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, excludes medically necessary treatment of cleft lip,

cleft palate.

 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.

 Hearing aids, except as specifically stated in this Policy, including but not limited to semi-implantable

hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs), limited to the least

expensive professionally adequate device. A hearing aid is any device that amplifies sound.

 Routine hearing tests except as specifically provided in this Policy under “Benefits/Coverage (What is

Covered).”

 Genetic screening or pre-implantation genetic screening: general population-based genetic screening is

a testing method performed in the absence of any symptoms or any significant, proven risk factors for

genetically linked inheritable disease.

 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.

 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.

 An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness

(myopia), astigmatism and/or farsightedness (presbyopia).

 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, medically necessary surgery or congenital defect of a Newborn child, or to treat congenital

hemangioma (port wine stains) on the face and neck of an insured person 18 years and younger, or for

Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy or

lumpectomy, or Medically Necessary gender affirming care.

 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.

 Non-medical counseling or ancillary services, including but not limited to: education, training, vocational

rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment

counseling, back school, return to work services, work hardening programs, driving safety, and services,

training, educational therapy or other nonmedical ancillary services for learning disabilities and

developmental delays, except as specifically stated in this Policy. This exclusion does not apply to health

education services for chronic diseases and self-care on topics such as stress management and nutrition.

 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 and blepharoplasty, except as specifically stated in this Policy.

 Any treatment, Prescription Drug, service or supply to treat sexual dysfunction, enhance sexual

performance or increase sexual desire

 The following services related to the treatment of fertility and/or Infertility, sterilization reversals; donor

semen and donor eggs; ovum transplants; in vitro fertilization, gamete intrafallopian transfer (GIFT),

zygote intrafallopian transfer (ZIFT), except as specifically stated in this Policy.

 Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).

 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.

 Blood administration for the purpose of general improvement in physical condition

 Orthopedic shoes (except when joined to Braces), shoe inserts, foot Orthotic Devices (except for

treatment as a result of diabetes).

 External and internal power enhancements or power controls for Prosthetic limbs and terminal devices.

 Myoelectric Prostheses peripheral nerve stimulators.

 Electronic Prosthetic limbs or appliances unless Medically Necessary, when a less-costly alternative is

not sufficient.

 Prefabricated foot Orthoses.

 Cranial banding/cranial Orthoses/other similar devices, except when used postoperatively for synostotic

plagiocephaly.

 Orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers.

 Orthoses primarily used for cosmetic rather than functional reasons.

 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.

 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 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, except as otherwise stated in this Policy under "Bariatric

Surgery."

 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 evaluations, except as otherwise specifically stated in this Policy.

 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.

 Educational services except for Diabetes Self-Management Training Program, and as specifically

provided or arranged by Cigna Healthcare.

 Nutritional counseling or food supplements, except as stated in this Policy.

 Exercise equipment, comfort items and other medical supplies and equipment not specifically listed as

Covered Services in the “Benefits/Coverage (What is Covered)” 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; wigs, 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.

 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

“Benefits/Coverage (What is Covered).”

 Foreign Country Provider charges except as specifically stated under “Foreign Country Providers” in the

section of this Policy titled “Benefits/Coverage (What is Covered).”

 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.

 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.

 Charges for the services of a standby Physician.

 Charges for animal to human organ transplants.

 Claims received by Cigna Healthcare after 15 months from the date service was rendered, except in the

event of a legal incapacity.

 Services obtained from a Dedicated Virtual Care Physician that are not Dedicated Virtual Urgent Care

or Dedicated Virtual Primary Care services.

 Abortions, except in cases of rape, incest, or when the life of the mother is endangered.