Page 46 - QCS.19 SPD - PPO

· Upper and lower jawbone surgery except as required for direct treatment of sudden traumatic Injury,
dislocation, tumors or cancer or as needed to safeguard your health due to a non–dental physiological
impairment. Surgical and non-surgical for Orthognathic and jaw alignment disorders, except as a
treatment of obstructive sleep apnea.
· Surgical and non-surgical treatment of obesity.

· Stand-alone multi-disciplinary smoking cessation programs.
· Breast reduction surgery that is determined to be a Cosmetic Procedure.

· Helicobacter pylori (H. pylori) serologic testing.
· Intracellular micronutrient testing.

· Health care services provided in an emergency department of a Hospital or Alternate Facility that are not
for an Emergency.
Providers

· Services performed by a provider who is a family member by birth or marriage. Examples include a
Spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or
herself.
· Services performed by a provider with your same legal address.

· Services provided at a free-standing or Hospital-based diagnostic facility without an order written by a
Physician or other provider. 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:
· Has not been actively involved in your medical care prior to ordering the service, or

· Is not actively involved in your medical care after the service is received.
· Foreign language and sign language interpreters.

Reproduction

· Health Care Services and related expenses for infertility treatments, including assisted reproductive
technology, regardless of the reason for the treatment.

· The following services related to gestational carrier or surrogate:
· Fees for the use of a gestational carrier or surrogate.

· Pregnancy services for a gestational carrier or surrogate who is not a Covered Person.
· Cost of donor eggs and donor sperm.

· Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and
ovarian tissue.
· The reversal of voluntary sterilization.

· Health Care Services and related expenses for surgical, non-surgical, or drug-induced pregnancy
termination. This exclusion does not apply to treatment of a molar pregnancy, ectopic pregnancy, or
missed abortion (commonly known as a miscarriage).

· In vitro fertilization regardless of the reason for treatment.
Services Provided under another Plan

· Health Care Services for when other coverage is required by federal, state or local law to be purchased or
bought through other arrangements. Examples include coverage required by workers' compensation or
similar legislation.

Page 41 Section 6- Exclusions: What The Plan Will Not Cover
PPO - 2017