Services Not Covered by Lumenos Georgia Health Insurance

Certain services and supplies - and certain medical expenses - are not eligible for benefits under your Traditional Health Coverage. However, you may be able to cover some of these costs using your account.

The following is a list of services that are not covered under your Traditional Health Coverage:

• For adoption expenses;
• For any surgical technique performed for the correction of myopia or hyperopia, including but not limited to keratomileusis, keratophakia, or radial keratotomy (plastic surgeries on the cornea in lieu of eyeglasses), and all related services;
• For any treatment, confinement, or service which is not recommended by, or any operation which is not performed by, an appropriate professional provider;
• For appliances for vision correction such as eyeglasses and contact lenses;
• For autopsies;
• For breast pumps;
• For charges for enteral feeding formulas, except in the following situations:
  • Prescription and over the counter enteral feeding formulas when considered the sole source of nutrition and administered via a feeding tube. This includes tube feeding supplies; or
  • Oral prescription enteral formulas when considered the sole source of nutrition;
  • Over the counter low protein food supplements when prescribed by a physician as part of a treatment plan for PKU.
  • Over the counter enteral feeding formulas are not covered when given orally, or are not the sole source of nutrition.
• For charges for equipment containing features of an aesthetic nature or features of a medical nature which are not required by the patient's condition;
• For charges for home births;
• For charges for sales tax;
• Charges for services for a member not eligible under the Lumenos plan at the time the service was rendered;
• For charges related to shipping and handling charges for any covered item;
• For the administration of the Flu Mist;
• For charges made for care or treatment which is not Medically Necessary (as determined by the Plan Administrator);
• For charges made which are in excess of the Reasonable and Customary charges (as determined by the Plan Administrator);
• For charges related to services or supplies for common household use, such as exercise cycles, air purifiers, air conditioners, water purifiers; allergenic mattresses; computer equipment and related devices, or supplies or a similar nature, whether or not prescribed by a physician;
• For charges the covered person has no obligation to pay;
• For cosmetic surgery, unless the covered person receives an injury which requires the surgery; or the cosmetic surgery is necessary to restore impaired bodily function resulting from disease, genetic abnormality, or previous therapeutic processes;
• For custodial care, domiciliary care or rest cures;
• For drugs and devices used for contraception, unless otherwise specified;
• For examination by a physician, related laboratory tests, x-rays and vaccines performed in the absence of specific symptoms on the part of the covered person (except as may be specifically provided herein);
• For examination or treatment ordered by a court in connection with legal proceedings will not be reimbursed;
• For expenses related to artificial reproductive procedures, including but not limited to artificial insemination and in vitro fertilization, or fertility drugs when used for treatment of infertility;
• For expenses related to exercise programs or use of exercise equipment, special diets or diet supplements,
• For expenses related to programs such as Nutri/System Program, Weight Watchers or physician supervised weight loss programs, or similar programs;
• For expenses related to treatment of nicotine addiction;
• For experimental or investigational procedures: Experimental or investigational procedures, drugs, or devices which the Plan Administrator determines are not generally recognized as being safe and effective by the medical community or ones that have not been approved by the FDA. The fact that an experimental or investigational service or an unproven service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in benefits if the procedure is considered to be experimental or investigational or unproven in the treatment of that particular condition;
• For full body scans or EBCT (heart scans);
• For gene therapy as a treatment for inherited or acquired disorders;
• For injury sustained or sickness contracted as the result of or caused by any act of war, or participation in a riot or civil disobedience;
• For items purchased over the counter (with the exception of glucomoters and blood pressure monitors when deemed Medically Necessary by a provider, which would be considered covered);
• For learning disabilities or developmental delay treatment, services, educational testing or associated training;
• For liposuction;
• For marriage counseling, unless services billed contain a valid mental health diagnosis;
• For massage therapy not rendered by a physician;
• For non-medical counseling of training services;
• For non-surgical treatment of temporomandibular joint disorders and related conditions by any method;
• For or in connection with a sickness or injury for which you or your dependent is eligible or covered under Workers' Compensation or similar law;
• For or in connection with an injury or sickness arising out of, or in the course of, any employment for wage or profit;
• For oral surgery or dental treatment except as may be specifically provided herein;
• For phototherapy devices related to seasonal affective disorder;
• For preservation of tissue or cells;
• For recreational or educational therapy or forms of non-medical self care or self-help training including health club memberships;
• For reversal of a sterilization procedures (i.e., vasectomy, tubal ligation);
• For routine physical exams and immunizations for employment, travel, summer camp or insurance purposes;
• For services provided without cost by any governmental agency, except where such exclusion is prohibited by law;
• For services rendered by a clergy;
• For services, treatment or supplies for which no charge would usually be made;
• For surrogate mother charges, unless the surrogate mother is eligible under the Lumenos plan at the time the services were rendered;
• For telephone consultations, charges for failure to keep a scheduled visit, charges for the copying of medical records, or charges for completion of a claim form;
• For the completion of any administrative forms;
• For extraction of wisdom teeth;
• For the services performed by any person who is a member of the covered person's immediate family consisting of the covered person, spouse, child(ren), brothers, sisters or parents or a family member who resides in the covered person's home;
• For transgender surgery;
• For treatment of sexual dysfunction not related to organic disease;
• For vision exams;
• For vitamins, except those which by law require a prescription order and are prescribed to treat a specific sickness or injury, or nutritional supplements;
• For vocational, work hardening or training programs regardless of diagnosis or symptoms that may be present, or for non-Medically Necessary education, except as specifically provided in this Plan;
• To the extent that you or your dependent is reimbursed or in any way indemnified for those expenses by or through Medicare or any other public program;
• For acupuncture services;
• For hearing aids;
• For immunizations for travel;
• For naturopathic services;
• For nutritional counseling;
• For orthopedic shoes except when an integral part of a brace;
• For preventive care services rendered by providers who do not offer discounts;
• For residential treatment facilities;
• For skilled nursing facilities;
• For weight reduction (i.e. gastric bypass, gastric plication, lap-band) surgeries;
• For wigs;
• For any other service or supply except as specifically provided herein.

The Plan sponsor continues to reserve its discretion to exclude other procedures relating to charges for any condition, disease, ailment or illness which are not deemed to be medically necessary, reasonable or otherwise covered. Thus, no inference should be drawn from the inclusion or exclusion of any specific condition, disease, ailment or illness, or its related treatment, diagnosis or care, in this section or otherwise.