If you have any questions whether our Plan will pay for a service, including inpatient hospital services, you have the right under law to have a written/binding advance coverage determination made for the service. Call our Plan and tell us you would like a decision if the service or item will be covered.
In addition to any exclusions or limitations described in the Benefits Chart in Section 3, or anywhere else in this booklet,the following items and services aren’t
covered except as indicated by our Plan:
1. Services that aren’t covered under the Original Medicare Plan unless services are specifically listed as covered in Section 3.
2. Services that aren’t reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our Plan as a covered service. As noted in Section 3, we provide all covered services according to Medicare guidelines.
3. Any of the services listed in this Section that aren’t covered will remain
not covered even if received at an emergency facility. For example, non-
authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility.
4. Experimental or investigational medical and surgical procedures,
equipment and medications determined by the Plan and Original Medicare
to not be generally accepted by the medical community, unless covered by Original Medicare or under an approved clinical trial. A health product or service is deemed experimental or investigational if one or more of the following conditions are met:
In 2008 CMS will continue to pay through Original Medicare for clinical trial items and services covered under the September 2000 National Coverage Determination that are provided to MA plan members. Experimental
procedures and items are those items and procedures determined by our Plan and the Original Medicare Plan to not be generally accepted by the medical community.
5. Acupuncture – Any acupuncture services or associated expenses.
6. Chiropractic – Those Health Services and associated expenses for medical and/or routine chiropractic services, except for manual manipulation of the spine to correct subluxation as outlined in Section 3, provided by chiropractors or licensed physicians only, according to Medicare guidelines.
7. Cosmetic Surgery – Those Health Services and associated expenses for cosmetic procedures. Cosmetic procedures are those procedures which improve physical appearance, but which do not correct or materially improve a physiological function, except when it is needed for prompt repair of accidental injury or to improve the function of a malformed part of the body. Breast surgery and all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast is covered according to Medicare guidelines.
8. Custodial Care – Custodial care is not covered, unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. Custodial Care includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
9. Dental Services, Surgery and Implants – Those Health Services and associated expenses for routine dental care (such as cleanings, fillings, or dentures) or other dental services are excluded according to Medicare guidelines. Certain dental services that you get when you are in the hospital may be covered according to Medicare guidelines.
10. Elective or Voluntary Enhancement – Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, mental performance, according to Medicare guidelines.
11. Foot Care – Routine foot care is generally not covered under Advantra Savings and is limited according to Medicare guidelines.
12. Hearing Services And Supplies – Routine hearing examinations and those services associated expenses for hearing aids, the examination for prescribing and fitting hearing aids, hearing therapy, and any related diagnostic hearing tests according to Medicare guidelines.
13. Homemaker Services and Charges imposed by immediate relatives or members of your household, according to Medicare guidelines.
14. Infertility Treatment – Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices.
(Medically necessary services for infertility are covered according to Original Medicare guidelines.)
15. Meals delivered to your home.
16. Naturopathic Services – The services and supplies provided by a naturopath and Homeopathic Services.
17. Obesity Services – Those health services and associated expenses for procedures intended primarily for the treatment of obesity and morbid obesity including, but not limited to, gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, wiring of the jaw, and health services of a similar nature are not covered unless Medically Necessary and covered under Original Medicare. Health services and associated expenses for weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature are not covered unless covered according to Original Medicare guidelines.
18. Orthopedic/Supportive Devices for the Feet – Orthopedic shoes, unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 3, in the Benefits Chart under “Outpatient Medical services”).
19. Private duty nursing services or nursing care on a full-time basis in your home or a facility, personal convenience items, such as a telephone or
television in your room at a hospital or skilled nursing facility, private room in a hospital, unless Medically Necessary and covered according to Original
Medicare guidelines.
20. Sexual Dysfunction – Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence and anorgasmy or hyporgasmy.
21. Vision – Routine eye exam and eyeglasses (except after cataract surgery), radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the Medicare allowable amount, we will reimburse veterans for the difference. Members are still responsible for the Medicare-allowable amount until the deductible has been met.