WHAT IS NOT COVERED EXCLUSIONS/LIMITATIONS
In this section, "service" means any treatment, therapeutic or diagnostic procedure, drug, equipment or device. When a service is excluded, all services necessary for the excluded service are also excluded. For example, follow-up visits in conjunction with a non-covered cosmetic surgery are excluded. The following services are NOT COVERED:
Conditions covered by workers' compensation.
Custodial care or care in an intermediate care facility.
Cosmetic Services. Plastic surgery or any other services that are indicated primarily to improve your appearance, and will not result in significant improvement in physical function. This exclusion does not apply to services:
a) that will correct significant disfigurement resulting from an injury or medically necessary surgery; or
b) following a covered mastectomy; or
c) that are necessary for treatment of a form of congenital hemangioma known as port wine stains on the face and neck of Members 18 years or younger.
Dental services and dental X-rays, including dental services following accidental injury to teeth; dental appliances; orthodontia; and dental services associated with medical treatment, including surgery on the jawbone and radiation therapy. This exclusion does not apply to medically necessary care covered by Medicare. Medically necessary orthodontic treatment and prosthodontic treatment of cleft lip or cleft palate for newborn members are covered when prescribed by a Physician, unless the member is covered for these services under a dental insurance policy.
Corrective Appliances and Artificial Aids. Artificial aids and corrective appliances, such as prosthetic devices, hearing aids, corrective lenses and eyeglasses, except that:
a) Physicians provide the services necessary to determine the need for such aids and appliances and attempt to make arrangements whereby they may be obtained.
b) Internally implanted devices for functional purposes, such as pacemakers and hip joints, are covered without charge.
c) Certain orthopedic braces are covered at a charge of 20% of member charges. See "Orthotic Devices," page 6.
d) Corrective appliances, such as obturators and speech and feeding appliances, required for treatment of cleft lip or cleft palate in newborn members are covered without charge when prescribed by a Plan Physician and obtained from sources designated by Kaiser Permanente.
e) Corrective lenses, eyeglasses and hearing aids are provided if covered by Medicare.
Durable medical equipment such as hospital beds and wheelchairs for use in your home including an institution used as your home.
Coverage is limited to the standard model of orthotic or prosthetic device or durable medical equipment that meets your medical needs. Convenience and luxury items and features are not covered.
All eye surgery which includes radial keratotomy that is solely for the purpose of correcting refractive defects.
Financial responsibility for services or any illness, injury or condition when the law requires such services to be provided by or received from a government agency.
Financial responsibility for services that an employer is required by law to provide.
Military service-connected conditions when care from the Veterans Administration is reasonably available.
Physical examinations and related services required for obtaining or maintaining employment or participation in employee programs, or for insurance or government licensing.
Experimental or Investigational Services.
a) A service is experimental or investigational for a Member's condition if any of the following statements apply to it as of the time the service is or will be provided to the Member. The service:
1. Cannot be legally marketed in the United States without the approval of the Food and Drug Administration (FDA) and such approval has not been granted; or
2. Is the subject of a current new drug or new device application on file with the FDA; or
3. Is provided as part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial or in any other manner that is intended to evaluate the safety, toxicity or efficacy of the service; or
4. Is provided pursuant to a written protocol or other document that lists an evaluation of the service's safety, toxicity or efficacy as among its objectives; or
5. Is subject to the approval or review of an Institutional Review Board (IRB) or other body that approves or reviews research concerning the safety, toxicity or efficacy of services; or
6. Is provided pursuant to informed consent documents that describe the service as experimental or investigational or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy; or,
7. The prevailing opinion among experts as expressed in the published authoritative medical or scientific literature is that (i) use of the service should be substantially confined to research settings, or (ii) further research is necessary to determine the safety, toxicity or efficacy of the service.
b) In making determinations whether a service is experimental or investigational, the following sources of information will be relied upon exclusively:
1. The Member's medical records;
2. The written protocol(s) or other document(s) pursuant to which the service has been or will be provided;
3. Any consent document(s) the Member or the Member's representative has executed or will be asked to execute to receive the service;
4. The files and records of the IRB or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body.
5. The published authoritative medical or scientific literature regarding the service as applied to the Member's illness or injury; and
6. Regulations, records, applications and other documents or actions issued by, filed with, or taken by the FDA, the Office of Technology Assessment, or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions.
c) If two or more services are part of the same plan of treatment or diagnosis, all of the services are excluded if one of the services is experimental or investigational.
d) Health Plan consults Medical Group and then uses the criteria described above to decide if a particular service is experimental or investigational.
Chiropractic services and services of chiropractors.
All services related to sexual reassignment.
Long-term physical rehabilitation and pulmonary rehabilitation.
Routine foot care services that are not medically necessary.
Services not generally and customarily available in the Service Area unless it is generally accepted medical practice to refer patients outside the Service Area for such service.
Services provided or arranged by criminal justice institutions for Members confined therein, unless care would be covered as Emergency Services.
Covered transplants are limited kidney transplants, heart transplants, heart-lung transplants, lung transplants, bone marrow transplants, cornea transplants, simultaneous kidney-pancreas transplants and liver transplants which are provided according to your Service Agreement.
Bone marrow transplants associated with high dose chemotherapy for germ cell tumors and neuroblastoma in children are covered. Bone marrow transplants associated with high dose chemotherapy for other solid tissue tumors are not covered. Other bone marrow transplants are covered in accord with your Service Agreement
Non-human and artificial organs and their implantation are excluded. Neither Health Plan nor Medical Group undertakes to provide a donor or donor organ or bone marrow or cornea or to assure the availability of a donor or donor organ or bone marrow or cornea or the availability or capacity of referral transplant facilities approved by Medical Group. However, we will pay the reasonable medical and hospital expenses of a donor or an individual identified by Medical Group as a prospective donor. If those expenses are directly related to a covered transplant. Medical Group determines that the Member satisfies medical criteria developed by Medical Group for receiving the services.
Medical Group provides a written referral for care to a transplant facility selected by Medical Group from a list of facilities it has approved. Medical Group's referral may be to a transplant facility out of the Service Area. Transplants are covered only at the facility selected by Medical Group for the particular transplant, even if another facility within the Service Area could also perform the transplant.
If, after referral, either Medical Group or the medical staff of the referral facility determines that the Member does not satisfy its respective criteria for the service involved. Health Plan's obligation is limited to paying for covered services provided prior to such determination.
For Substance Abuse:
Inpatient services of a specialized facility for alcohol and drug rehabilitation unless you are a member of a group that has purchased additional coverage for alcohol and drug dependency treatment.
Counseling for a patient who is not responsive to therapeutic management.
Care as a condition of probation, parole or any other court order unless a Medical Group Physician determines such care to be medically necessary and appropriate.
Continuation in a course of treatment for patients who are disruptive or physically abusive.
For Mental Health Conditions:
Special education, counseling, therapy or care for learning deficiencies or behavioral problems, whether or not associated with a manifest mental disorder, retardation or other disturbance, e.g., attention deficit disorder.
Organic brain syndromes.
Court-ordered testing, testing for ability, aptitude, intelligence or interest.
Care as a condition of probation or parole or to be used in court proceedings unless a Medical Group Physician determines such care is medically necessary and appropriate.
For Family Planning and Infertility:
Services to reverse voluntary, surgically induced infertility.
The cost of donor semen, donor eggs, and services related to their procurement and storage.
Services for conception by artificial means including, but not limited to, in vitro fertilization, ovum transplants, gamete intrafallopian transfer or zygote intrafallopian transfer.
The following services and supplies are covered on a LIMITED basis:
Outpatient physical therapy, speech therapy and occupational therapy are limited to up to two months of treatment or 30 visits (if 30 visits have not been used in two months) per condition to restore physical function which has been lost due to illness or injury.
Occupational therapy is limited to services to achieve and maintain improved self-care and other customary activities of daily living.
Speech therapy is limited to treatment for speech impairments of specific organic origin. Many pediatric conditions do not qualify for coverage because they lack a specific organic cause and may be long-term and chronic in nature.
Treatment in a multidisciplinary rehabilitation program for up to two months is provided in a designated rehabilitation facility as prescribed by a Plan Physician when significant improvement in function is achievable.
Immunizations are limited to those that are not experimental and are consistent with accepted medical practice.
Prescribed supplies dispensed in Plan pharmacies will be provided at a charge of 20% of member charges per prescription or refill for a two-month supply per item. Such items include, but are not limited to, home glucose monitoring supplies, disposable syringes, glucose test tablets and tape and acetone test tablets.
Kaiser Permanente has no responsibility when:
Unusual circumstances, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes not involving Kaiser Permanente, disability of a significant number of personnel, or similar events result in a delay in providing services or inability to provide services. However, within the limitation of available facilities and personnel, we will use our best efforts to provide services and other benefits. In cases of labor disputes involving Kaiser Permanente, we may defer the provision of non-emergent care until after the labor dispute.
You refuse recommended treatment for conditions for personal reasons when Medical Group Physicians believe no professionally acceptable alternative treatment exists.