Expenses not covered

Health services and supplies that do not meet the definition of a covered health service. (See "Medical plan definitions.") Covered health services are those health services including services, supplies or pharmaceutical products, which UnitedHealthcare determines to be all of the following:
Medically necessary.
Described as a covered health service in this SPD under "Covered medical expenses."
Not otherwise excluded in this SPD "Expenses not covered."
Health services related to a non-covered health service: When a service is not a covered health service, all services related to that non-covered health service are also excluded. This exclusion does not apply to services the Plan would otherwise determine to be covered health services if they are to treat complications that arise from the non-covered health service.

Health services provided in a foreign country, unless required as emergency health services.
Services and supplies that are not necessary for the diagnosis, care or treatment of the disease or injury involved.
Experimental or investigational services or unproven services, unless the Plan has agreed to cover them as defined in "Medical plan definitions." This exclusion applies even if experimental or investigational services or unproven services, treatments, devices or pharmacological regimens are the only available treatment options for your condition.
Items and services provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient.
A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
Items and services provided by the research sponsors free of charge for any covered member enrolled in the trial.
Services or supplies that are experimental, investigational or unproven (However, this exclusion will not apply to services or supplies [other than drugs] received in connection with a disease if UnitedHealthcare determines that the disease is expected to cause death within one year in the absence of effective treatment, and the service or supply is effective or shows promise of being effective for that disease. This exclusion will not apply to drugs that have been designated as an investigational new drug or are being studied at the Phase III level in a national clinical trial by the National Cancer Institute, if UnitedHealthcare determines that the drug is effective or shows promise of being effective for the disease.) If you are not a participant in a qualifying clinical trial and have a sickness or condition that is likely to cause death within one year of the request for the treatment, UnitedHealthcare may at its discretion, consider an otherwise experimental or investigational service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare must determine that, although unproven, the service has significant potential as an effective treatment for that sickness or condition.
Services, treatment, educational testing or training related to learning disabilities or developmental delays except for speech therapy services.
Care furnished mainly to provide a surrounding free from exposure that can worsen the member's disease or injury
Treatment of covered healthcare providers who specialize in the mental healthcare field and who receive treatment as part of their training in that field
Services of a resident physician or intern rendered in that capacity
Expenses above the eligible expense fee limits set by UnitedHealthcare
Hospital or other facility expenses for custodial care
Services and supplies furnished, paid for or for which benefits are provided or required because of a person's past or present service in the armed forces
Services and supplies furnished, paid for or for which benefits are provided or required under any law of a government (This does not include a plan established by a government for its own employees or their dependents, or Medicaid.)
Charges for eye refractions or vision examinations
Charges for eyeglasses or contact lenses to correct refractive errors
Eye surgery to eliminate refractive errors (such as radial keratotomy or LASIK)
Services or supplies for education, special education or job training, whether or not given in a facility that also provides medical or psychiatric treatment
Charges for plastic surgery, reconstructive surgery, cosmetic surgery, liposuction (except liposuction for lipedema paid as reconstructive procedure) or other services and supplies which improve, alter or enhance appearance, whether or not for psychological or emotional reasons. This exclusion will NOT apply if the service or supply is needed:
To improve the function of a body part (other than a tooth) that is malformed as a result of a severe birth defect or as a direct result of disease or surgery performed to treat a disease or injury
To repair an injury as long as surgery is performed in the calendar year of the accident which causes the injury or in the next calendar year
For breast reduction surgery in which UHC determines is requested to treat a physiologic functional impairment or for coverage required by the Women's Health and Cancer Rights Act of 1998
For medically necessary treatments for gender dysphoria
Charges for therapy, supplies or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis
Charges for cosmetic procedures for gender dysphoria including:
Abdominoplasty
Blepharoplasty
Body contouring, such as lipoplasty. Removal of excessive skin and subcutaneous tissue, etc.
Brow reduction, augmentation and lift
Cheek implants and lipofilling
Chin reshaping
Injection of fillers or neurotoxins
Face lift, forehead lift, or neck tightening
Facial bone remodeling
Hair removal, except as part of a genital reconstruction procedure by the physician for the treatment of Gender Dysphoria
Hairline advancement and transplantation
Jaw reconstruction
Lip augmentation
Lip reduction
Lipofilling and Liposuction
Mastopexy
Penile transplants
Rhinoplasty
Skin resurfacing
Uterine transplants.
The following fertility treatment-related services:
Cryo-preservation and other forms of preservation of reproductive materials except as described under fertility Services. This exclusion does not apply to short-term storage (less than one year) and retrieval of reproductive materials for which benefits are provided as described "Additional Coverage Details".
Long-term storage (greater than one year) of reproductive materials such as sperm, eggs, embryos, ovarian tissue and testicular tissue.
Donor services and non-medical costs of oocyte or sperm donation such as donor agency fees.
The following services related to a gestational carrier or surrogate:
Fees for the use of a gestational carrier or surrogate.
Insemination or InVitro fertilization procedures for surrogate or transfer of an embryo to gestational carrier.
Pregnancy services for a gestational carrier or surrogate who is not a covered person.
Donor, gestational carrier or surrogate administration, agency fees or compensation.
The following services related to donor services for donor sperm, ovum (egg cell) or oocytes (eggs), or embryos (fertilized eggs):
Purchased egg donor (i.e., clinic or egg bank) – The cost of donor eggs. This refers to purchasing a donor egg that has already been retrieved and is frozen.
Purchased donor sperm (i.e., clinic or sperm bank) – The cost of procurement and storage of donor sperm. This refers to purchasing donor sperm that has already been obtained and is frozen or choosing a donor from a database.
The reversal of voluntary sterilization.
Fertility services not received from a Designated Provider (except for covered persons who do not live within a 60 mile radius of a Fertility Solutions Designated Provider as determined by the Plan) .
Assisted Reproductive Technology procedures done for non-genetic disorder sex selection or eugenic (selective breeding) purposes.
Infertility treatment with voluntary sterilization currently in place (vasectomy, bilateral tubal ligation).
Infertility treatment following unsuccessful reversal of voluntary sterilization.
Infertility treatment following the reversal of voluntary sterilization (tubal reversal/reanastomosis; vasectomy reversal/vasovasostomy or vasoepididymostomy).
Nutritional counseling for the following: obesity/weight loss, conditions which have not been shown to be nutritionally related, including but not limited to chronic fatigue syndrome and hyperactivity.
Charges for food of any kind, infant formula, standard milk-based formula, and donor breast milk. This exclusion does not apply to specialized enteral formula for which Benefits are provided as described under Enteral Nutrition
Charges for marriage, family, child, career, social adjustment, pastoral or financial counseling without a medical diagnosis
Charges for acupressure, aromatherapy, hypnotism, massage therapy, rolfing and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health
Services provided by a close relative or anyone who resides in the patient's home (Close relatives include the patient's spouse, and any child, sibling or parent of the employee or spouse.)
Travel or transportation expenses, even if ordered by a physician, associated with an organ transplant, as well as the expenses incurred by an organ donor whether or not the person is covered by the Plan, except as described under "Travel and lodging assistance program for complex medical conditions."
Health services for transplants involving animal organs or animal-assisted therapies.
Charges for treatment of an injury or illness due to an act of war (declared or undeclared) or contracted while on duty with any military service for any country
Charges for treatment of obesity, unless the patient meets specific medical criteria as described under "Obesity surgery."
Surgical treatment of obesity unless there is a diagnosis of morbid obesity as described under "Obesity surgery."
Charges for insulin syringes, lancets, insulin pen injectors and diabetic test strips (These expenses are covered under the prescription drug plan.)
Services provided for comfort or convenience such as televisions, telephones, air conditioners, air purifiers, humidifiers, dehumidifiers, beauty or barbershop services or home remodeling to accommodate a health need.
Prescribed or non-prescribed medical supplies.

Medical foods for which benefits are provide (including medical foods to support enteral nutrition).
Diabetic supplies for which benefits are provided.
Ostomy supplies for which benefits are provided.
Urinary catheters for which benefits are provided.
Compression stockings.
Ace bandages.
Gauze and dressings.
Dental services. This exclusion will not apply to anesthesia and associated hospital and facility charges that are not covered under the dental plan and are provided when, in the opinion of the treating dentist, any of the following criteria apply:
The related procedure involves extracting six or more teeth in various quadrants
Use of local anesthesia is considered ineffective because of acute infection, anatomic variation, or allergy
The procedure involves multiple extractions or restorations for a child under age four
There is a concurrent hazardous medical condition
The procedure is intended to address extensive oral-facial and/or dental trauma and would be ineffective or compromised if performed using local anesthesia

Prescription drugs and over-the-counter medications or supplies (These expenses may be covered under the prescription drug plan.)
Self-administered or self-infused medications. This exclusion does not apply to medications which, due to their characteristics, (as determined by UnitedHealthcare), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to certain hemophilia treatment centers contracted that are contracted with a specific hemophilia treatment center fee schedule that allows medications used to treat bleeding disorders to be dispensed directly to covered individuals for self-administration.
Routine foot care
Orthotic appliances and devices that straighten or re-shape a body part, except as covered under durable medical equipment (DME). This exclusion does not apply to cranial molding helmets and cranial banding that meet clinical criteria.

Non-powered exoskeleton devices are excluded. Intracellular micronutrient testing is excluded.
Cranial molding helmets and cranial banding are excluded except when used to avoid the need for surgery, and/or to facilitate a successful surgical outcome.
Health services for organ and tissue transplants except as identified under "Organ transplant benefits", unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare's transplant guidelines
Growth hormone therapy
Domiciliary care
Liposuction
Custodial care
Respite care
Rest cures
Psychosurgery
Treatment of benign gynecomastia (abnormal breast enlargement in males)
Medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea
Appliances for snoring
Personal trainer
Naturalist
Holistic or homeopathic care
Art therapy, music therapy, dance therapy, animal-assisted therapy and other forms of alternative treatment as defined by the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health. This exclusion does not apply to manipulative treatment and non-manipulative osteopathic care for which benefits are provided
Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered when:
Required solely for purposes of career, education, sports or camp, travel employment insurance, marriage or adoption (This exclusion does not include vaccines that are required by Stryker. If these vaccinations are required by your position the vaccinations are covered at 100%.)
Related to judicial or administrative proceedings or orders
Conducted for purposes of medical research
Required to obtain or maintain a license of any type (This exclusion does not include vaccines that are required by Stryker. If these vaccinations are required by your position the vaccinations are covered at 100%.)
Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends
In the event that an out-of-network provider waives copayments, coinsurance and/or the annual deductible for a particular health service (No benefits are provided for the health service for which the copayments, coinsurance and/or annual deductible are waived, not pursued, or not collected.)
Charges in excess of any specified limitation
Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), if the services are considered to be dental in nature, including oral appliances
Any charges for missed appointments, room or facility reservations, completion of claim forms or record processing
Any charges higher than the actual charge (The actual charge is defined as the provider's lowest routine charge for the service, supply or equipment.)
Any charge for services, supplies or equipment advertised by the provider as free
Any charges by a provider sanctioned under a federal program for reason of fraud, abuse or medical competency
Any charges prohibited by federal anti-kickback or self-referral statutes
Outpatient rehabilitation services, spinal treatment or supplies including, but not limited to, spinal manipulations by a chiropractor or other doctor, for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring
Spinal treatment, including chiropractic and osteopathic manipulative treatment, to treat an illness such as asthma or allergies
Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from an injury, stroke, congenital anomaly or developmental delay
Devices and computers to assist in communication and speech except for dedicated speech generating devices and tracheo-esophageal voice devices for which benefits are provided
Habilitative services or therapies for the purpose of general well-being or condition in the absence of a disabling condition. Any expenses you incur pursuing a claims appeal that you file.
Certain new pharmaceutical products and/or new dosage forms until the date as determined by UnitedHealthcare or their designee, but no later than December 31st of the following calendar year.