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Anthem Blue Cross : Exclusions & Limitations

Exclusions & Limitations

PW_A117000
 
This is a representative listing of major exclusions and limitations. A more detailed listing can be found in the Combined Evidence of Coverage and Disclosure Form/Certificate.  
Exclusions and Limitations Common to All Medical Plans:
Any amounts in excess of the maximum amounts as stated in the Combined Evidence of Coverage and Disclosure Form/Certificate.
Services or supplies determined by Anthem Blue Cross not to be medically necessary.
Services received before your effective date.
Services received after your coverage ends.
Any conditions 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 you do not claim those benefits.
Services for which you are not legally obligated to pay for or services which no charge is made to you in the absence of insurance coverage.
Services not specifically listed in the Combined Evidence of Coverage and Disclosure Form/Certificate as covered services.
Professional services received from a person who lives in the member's home or who is related to the member by blood, marriage or adoption.
Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses and eye refractions, except as specifically stated in the Combined Evidence of Coverage and Disclosure Form/Certificate.
Eye surgeries performed solely for the purpose of correcting refractive defects such as near-sightedness (myopia), astigmatism and far-sightedness (presbyopia).
Hearing aids
Services primarily for weight reduction or treatment of obesity or any care which involves weight reduction as the main method of treatment, except medically necessary treatment of morbid obesity with Anthem Blue Cross prior authorization.
Sterilization reversal and any other services for infertility except as specifically stated in the Combined Evidence of Coverage and Disclosure Form/Certificate. Any amounts in excess of the lifetime maximum for infertility services.
Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex changes.
All dental services, including diagnostic, preventative, x-rays, dentures, bridges, crowns, caps, orthodontic services, braces and other orthodontic appliances and supplies, dental implants and related procedures, except as specifically stated in the Combined Evidence of Coverage and Disclosure Form/Certificate.
Cosmetic surgery or other services that are performed to alter or reshape normal structures of the body in order to improve appearance.
Routine physical examinations for insurance, employment, license or school.
Treatment of mental or nervous disorders (including nicotine use) or psychological testing except as specifically stated under the benefits section of the Combined Evidence of Coverage and Disclosure Form/Certificate.
Custodial care.
Services which are experimental or investigational in nature.
Educational services, except as specifically provided or arranged by Anthem Blue Cross.
Nutritional counseling, except as specifically provided or arranged by Anthem Blue Cross.
Services provided by a local, state or federal government agency, except when payment is expressly required by federal or state law.
Conditions caused by an act of war or the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy.
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.
Contraceptive devices unless your physician determines that oral contraceptive drugs are not medically appropriate
Consultations provided by telephone or facsimile machines.
Items which are furnished primarily for personal comfort or convenience including, but not limited to air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, shoes, spas, elevators, hair pieces, diapers and supplies for hygiene or beautification.
Services or supplies furnished and billed by a provider outside the U.S., unless for medical emergencies.
All durable medical equipment used for infusion therapy.
Health club memberships.
Services for which you are entitled to receive Medicare benefits, whether or not they are actually paid.
Charges in excess of the limited fee schedule and reasonable and customary amounts determined by Anthem Blue Cross.
Food supplements for formulas and special food products that are prescribed by a physician in consultation with a metabolic disease specialist if it is deemed medically necessary to prevent complications of phenylketonuria (PKU).
 
Additional Exclusion and Limitations Applicable only to the Premier and Advantage PPO Plans:
Inpatient or outpatient services of a private duty nurse, except as specifically stated under the benefits section of the Combined Evidence of Coverage and Disclosure Form.
Preexisting conditions, except as specifically stated in the Combined Evidence of Coverage and Disclosure Form.
Care and treatment furnished in a non-contracting hospital, except for medical emergencies.
Routine hearing exams, except as specifically listed in the Combined Evidence of Coverage and Disclosure Form.
Routine physical exams, except as specifically stated in the Combined Evidence of Coverage and Disclosure Form.
 
Additional Exclusions and Limitations Applicable only to the HMO Plans:
Care not authorized by your PMG or IPA.
Amounts in excess of customary and reasonable charges for care rendered by a non-participating provider without a referral from your PMG or IPA.
Routine immunizations and immunizations for foreign travel.
Rehabilitative care, such as physical therapy, occupational therapy and speech therapy, unless provided by a Home Health Agency, a visiting Nurse Association, or except as specifically stated in the Combined Evidence of Coverage and Disclosure Form.
Conditions of the jaw or teeth secondary to malocclusion or orthognathic conditions.
Growth hormone treatment.
Acupuncture/acupressure.
 
Additional Exclusions and Limitations Applicable only to the Basic PPO Plan:
Physician office visits and associated costs, except Well Baby and Preventative Care services as described in the Certificate.
Inpatient or outpatient services of a private duty nurse, except as specifically stated in the Certificate.
Outpatient drugs, medications or other substances dispensed or administered in any outpatient setting.
Physical or occupational medicine or chiropractic services, except when provided during an inpatient hospital confinement.
Outpatient speech therapy.
Care and treatment furnished in a non-contracting hospital except for medical emergencies.
Routine hearing exams except as specifically stated in the Certificate.
 
Additional Exclusions and Limitations Applicable only to the High Deductible EPO Plan:
Services from a non-participating provider except as specifically stated in the benefits section of the Combined Evidence of Coverage and Disclosure Form.
Inpatient or outpatient services of a private duty nurse, except as specifically stated in the benefits section of the Combined Evidence of Coverage and Disclosure Form.
Care and treatment furnished in a non-contracting hospital or ambulatory surgical center except for medical emergencies.
Routine hearing exams, except as specifically listed in the Combined Evidence of Coverage and Disclosure Form.
Routine physical exams, except as specifically listed in the Combined Evidence of Coverage and Disclosure Form.
 
Additional Exclusion and Limitations Applicable only to the Saver PPO Plan:
Physician office visits and associated costs, except as specifically described in the Certificate.
Inpatient or outpatient services of a private duty nurse, except as specifically described in the Certificate.
Physical or occupational medicine or chiropractic services, except provided during an inpatient hospital confinement.
Outpatient speech therapy
Care and treatment furnished in a non-contracting hospital, except for medical emergencies.
Outpatient drugs, medications or other substances dispensed or administered in any outpatient setting in excess of the maximum amount stated in Certificate.
 
Exclusions and Limitations Common to All Dental Plans:
Services or supplies determined by Anthem Blue Cross not to be medically necessary.
Services received before your effective date or after your coverage ends.
Services for which you are not legally obligated to pay or for services which no charge is made to you in the absence of insurance coverage.
Any conditions 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 you do not claim those benefits.
Conditions caused by an act of war or the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy.
Services provided by a local, state or federal government agency, except when payment is expressly required by federal or state law.
Any services to the extent that you are entitled to receive Medicare benefits for those services, whether or not Medicare benefits are actually paid.
Services for cysts and neoplasms.
All hospital costs and any additional fees charged by the dentist for hospital treatment.
Professional services received from a person who lives in the insured's home or who is related to the member by blood, marriage or adoption.
Prescription drugs.
Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a dentist.
Gold, porcelain or resin fillings on primary teeth.
 
Exclusions and Limitations Common to all PPO/FFS Dental Plans:
Diagnosis or treatment of the joint of the jaw and/or occlusion (the way the upper and lower teeth meet) services, supplies or appliances provided in connection with any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means.
Oral examinations exceeding two visits per year.
Prophylaxis (teeth cleaning) exceeding two (2) treatments per year.
Any services performed for cosmetic purposes including, but not limited to, bleaching of non-vital discolored teeth & bonding procedures.
Any procedure not specifically listed as a covered service.
Any amounts in excess of the maximum amounts stated in the "Maximum Benefits" section of the Certificate.
Replacement of an existing prosthesis which has been lost or stolen, or which, in the opinion of the dentist, is or can be made satisfactory.
Replacement of a fixed or removable prosthesis if such replacement occurs within five years of the original placement, unless the prosthesis is a stayplate used during the healing period for recently extracted anterior teeth. Initial placement of prosthetics if teeth being replaced have been missing before insured was covered by the Plan.
Diagnosis or treatment of the joint of the jaw and/or occlusion (the way the upper and lower teeth meet) services, supplies or appliances provided in connection with:

Any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves or other tissues for any reason or by any means; or

Any treatment, including crowns, caps and/or bridges to change the way the upper and lower teeth meet (occlusion); or

Treatment to change vertical dimension (the space between the upper and lower jaw) for any reason or by any means, including the restoration of vertical dimension because teeth have worn down.

Procedures requiring appliances or restorations (other than those for replacement of structural loss from caries) that are necessary to alter, restore or maintain occlusions. These include, but are not limited to:

Changing the vertical dimension

Replacing or stabilizing lost tooth structure by attrition, abrasion or erosion

Realignment of teeth

Gnathological recording

Occlusal equilibration

Splinting

Services not included as a covered procedure, unless they are similar in nature to an included procedure; in such event the benefit payable will be based on the most nearly comparable services included.
Services or supplies that are considered experimental or investigational in nature.
More than one set of full-mouth x-rays or a panarex in a three-year period.
Fluoride applications are limited to once per year up to the age of 18.
Dental treatment or expenses incurred in connection with the correction of congenital or developmental malformation.
Adjustment, repairs, or relines of prostheses for a period of six months from the initial placement if the prostheses were paid for under the Certificate.
Inlays, onlays, crowns, fixed bridges or removable cast partials for patients under sixteen (16) years of age. Space maintainers for Insureds over sixteen (16) years of age.
If an insured transfers from the care of one dentist to another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, Anthem Blue Cross Life and Health Insurance Company shall be liable only for the amount it would have been liable for had one dentist rendered the services.
Prescribed drugs, pre-medication or analgesia.
Oral hygiene instruction.
Materials implanted into or on bone or soft tissue and all adjunctive services (including, but not limited to, surgery, cleaning, etc.) performed in conjunction with the placement or removal of implants.
Replacement of teeth missing prior to the effective date of coverage with partial dentures, complete dentures or fixed bridges.
Services on teeth that appear to have a poor prognosis, or that are not reasonably necessary or customarily performed are not covered.
If multiple endodontic treatments are necessary on the same tooth within a period of one year, the allowance will be made for only one procedure.
The extraction of immature erupting third molars and nonpathologic, asymptomatic third molar extractions is excluded.
Temporary services are considered an integral part of the final services rather than a separate service, and are therefore not eligible for benefits.
Sealants are limited to one treatment every 36 months per tooth for children 15 years of age for permanent first and second molars, unrestored.
Periodontal scaling and root planing will be limited to once quadrant per 24 months. Polishing of all teeth is considered part of this treatment.
Osseous and mucogingival surgery will be limited to once per quadrant per 36 months.
Gross debridement allowed one time at the beginning of a periodontal treatment plan. Subsequent requirement for debridement is considered patient neglect and would be the financial responsibility of the insured.
Precision attachments, characterization or personalization of dentures if excluded.
Ligation and crown lengthening are not covered.
Additional Exclusions and Limitations Specific to the Standard Option PPO and FFS Dental Plans:
Braces, appliances and all related orthodontic services.
 
Additional Exclusions and Limitations Specific to the Basic Option PPO and FFS Dental Plans:
Braces, appliances and all related orthodontic services.
 
Additional Exclusions and Limitations Specific to the High Option PPO and FFS Dental Plans:
Orthodontic services: These orthodontic exclusions and limitations are in addition to the basic dental plan exclusions and limitations:

Treatment of orthodontic cases begun prior to the Insured's Effective Date of coverage or after the termination of eligibility for coverage.

Myofunctional therapy and related services. (Myofunctional therapy involves the use of muscle exercises as an adjunct to orthodontic mechanical correction or malocclusion.)

Surgical procedures incidental to orthodontic treatment, including, but not limited to, extraction of teeth, solely for orthodontic reasons, exposure of impacted teeth, correction of micrognathia or macrognathia, or repair of cleft palate.

Treatment related to temporomandibular joint (jaw joint) disturbances and/or hormonal imbalance.

Orthodontic records, including, but not limited to, cephalometric tracing, photographs, study models and diagnostic radiographs.

Replacement of lost or stolen orthodontic appliances or repair of orthodontic appliances broken due to negligence of the insured.

Any orthopedic/orthodontic treatment which may be deemed advantageous or necessary by the orthodontist prior to the 24 months of standard active treatment. Orthodontic treatment for malocclusions, which, in the opinion of the orthodontist will not produce beneficial results.

Orthodontic treatment in conjunction with oral surgical procedures, including but not limited to orthognathic surgery.

Changes in treatment necessitated by an accident of any kind.

The retreatment of a previously treated orthodontic case is not covered.

Special orthodontic appliances including but not limited to lingual or invisible braces, sapphire or clear braces, or ceramic braces are considered cosmetic and not included as covered benefits under the Certificate.

 
Exclusions and Limitations Common to All HMO Dental Plans:
Dental services must be received from the member's participating dental office unless an exception is specifically authorized by the member's selected participating dental office and/or Anthem Blue Cross in writing.
Any amounts in excess of the maximum amounts stated in the combined evidences of coverage and the disclosure form.
Any treatment to correct a dental condition that resulted from dental services performed by a non-participating dentist while this coverage is in effect, and any dental services started by a non-participating dentist will not be the responsibility of the participating dental office or Anthem Blue Cross for completion.
Treatment of fractures or dislocations.
Histopathological exams, and/or removal of tumors, cysts, neoplasms and foreign bodies.
Teeth with questionable, guarded or poor prognosis are not covered for endodontic, periodontal surgery, or crown and bridge.
Orthodontic Exclusions and Limitations:

Orthodontic services must be received from a participating orthodontic office.

In the event of a member's loss of coverage, for any reason, and at the time of loss of coverage, the member is still receiving orthodontic treatment during the treatment period, the member and NOT Anthem Blue Cross will be responsible for the remainder of the cost for that treatment, at the participating orthodontist's usual and customary fee, prorated for the number of months of treatment remaining.

Myofunctional therapy and related services.

Replacement of lost or stolen orthodontic appliances or repair of orthodontic appliances broken due to negligence of the member.

Surgical procedures incidental to orthodontic treatment, including, but not limited to extraction of teeth, solely for orthodontic reasons exposure of impacted teeth, correction of micrognathia or macrognathia, or repair of cleft palate.

Treatment of orthodontic cases begun prior to the member's effective date of eligibility or after the termination of eligibility for coverage.

Changes in treatment necessitated by an accident of any kind.

Treatment related to the joint of the jaw (temporomandibular joint, TMJ) and/or hormonal imbalance.

 
Additional Exclusions and Limitations Specific to the DentalNet Plan:
Treatment of the joint of the jaw and/or occlusion (the way the upper and lower teeth meet) services, supplies or appliances provided in connection with any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means.
Oral examinations including prophylaxis (teeth cleaning) exceeding two visits per year.
Any services performed for cosmetic purposes, (including, but not limited to, bleaching for non-vital discolored teeth and bonding procedures).
Services that are considered experimental or investigative in nature.
Any procedure not specifically listed as a covered service.
Periodontal scaling and root planing and/or gingival curettage are limited to one course of therapy per quadrant per year.
Partial dentures are not eligible for replacement within five years of original placement unless required as a result of additional tooth loss which cannot be restored by modification of the existing partial denture. Crowns, bridges, inlays and/or complete dentures are not eligible for replacement within five years of original placement.
For crowns, nonremovable bridges and periodontal surgery, the member must meet the six-month waiting period described in the Exclusions and Limitations section of the Evidence of Coverage before any of these services are covered.
Complete and/or partial dental relines are limited to one per denture in a 12-month period.
In cases where multiple acceptable methods of treatment exist, the least expensive professionally acceptable treatment is considered the covered benefit.
The use of alloys with 25 percent or more noble metal content for any restorative procedure is considered optional and if used, the additional cost for such alloy is the member's responsibility.
Removal of impacted teeth is limited to impactions which show radiographic evidence of pathologic condition or for which the experiences symptoms of infection, swelling or chronic pain.
Pediatric dental specialist services are limited to $500.00 per year for each child. Charges in excess of $500.00 will be your financial responsibility.
For active orthodontic treatment extending beyond the 24-month period, but before the retention phase begins, the member will be required to pay the participating orthodontist up to $55 for each additional month of active treatment.
Retention services include initial fabrication, placement, observation and adjustment of passive retention appliances for a 12-month period. The retention services fee of $250is the member's responsibility and payable at the beginning of the retention phase of treatment. Retention service fees are subject to review and modification on an annual basis.
Dental services necessary solely for cosmetic reasons, including but not limited to, bleaching of discolored teeth and bonding procedures.
Coverage for any dental treatment which, because of the member's general health, or mental, emotional, behavioral or physical limitations cannot be performed in the participating dental office.
Replacement of an existing prosthesis which has been lost or stolen; or which in the opinion of the dentist is or can be made satisfactory.
Dental treatment or expenses incurred in connection with the correction of congenital or developmental malformations.
Tooth implantation or transplantation, orthognathic surgery, soft tissue or osseous grafts, hemisection, root amputation, apexification, alveoloplasty, vestibuloplasty or ostectomy procedures.
Space maintainers, inlays, onlays, crowns, fixed bridges or removable cast partials for members under sixteen years of age.
Materials implanted into or on bone or soft tissue and all adjunctive services (including, but not limited to, surgery, prosthesis, cleanings, etc.) performed in conjunction with the placement or removal of implants.
Dental treatment or procedures requiring or associated with fixed prosthodontic restorations (other than for replacement of structure loss from dental decay) required in conjunction with altering vertical dimension, replacing tooth structure lost by attrition, erosion or abrasion.
Dental treatment or expenses incurred in connection with periodontal splinting.
General anesthesia, inhalation sedation, intravenous sedation or intramuscular sedation.
Porcelain or composite labial veneers for fixed prosthodontics, posterior to the second bicuspid and composite fillings posterior to the cuspid.
A member must be enrolled for a period of six (6) consecutive months under the Evidence of Coverage to be eligible for benefits for services related to surgical periodontics and fixed prosthodontics or individual crown restorations.
The re-treatment of a previously treated orthodontic case.
Orthodontic records including but not limited to cephalometric tracings, photographs, study models and diagnostic radiographs.
Any orthopedic/orthodontic treatment which may be deemed advantageous or necessary by the participating orthodontist prior to the 24 months of standard active treatment.
Orthodontic appliances including but not limited to braces, sapphires or clear braces, or ceramic braces.
 

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.