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Exclusions and Limitations: What Is Not Covered by This Policy
Excluded Services
In addition to any other exclusions and limitations described in this Policy, there are no benefits provided for
the following:
1. Services obtained from a Non-Participating/Out-of-Network Provider, except for (a) Emergency
Services; (b) non-Emergency Services provided to an Insured Person at a Participating Facility if the non-
Emergency Services involve surgical or ancillary services provided by a Non-Participating Provider; (c)
services for an Urgent Health Problem in an office, Urgent Care facility, or another outpatient facility and
the related Physician and other related Provider services; (d) Medically Necessary services that are not
available from a Participating Provider.
2. Any amounts in excess of maximum benefit limitations of Covered Expenses stated in this Policy.
3. Services not specifically listed as Covered Services in this Policy in the sections titled “Comprehensive
Benefits: What the Policy Pays For,” “Prescription Drug Benefits,” “Pediatric Vision Care,” and the benefit
schedule.
4. Services or supplies that are not Medically Necessary, except for preventive care services as provided
in this Policy.
5. Services or supplies that are considered to be for Experimental Procedures or Investigational
Procedures or Unproven Procedures, except as otherwise stated in this Policy under “Clinical Trials.”
6. Services received before the Effective Date of coverage.
7. Services received after coverage under this Policy ends.
8. Services for which you have no legal obligation to pay or for which no charge would be made if you
did not have a health plan or insurance coverage.
9. Any condition 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,
except coverage for any medical condition pursuant to such exclusion if (i) an award of the Workers’
Compensation Commission denies compensation benefits relating to such medical condition and no
request for review of such award is made pursuant to and within the time prescribed by applicable law; or
(ii) an award of the Workers’ Compensation Commission, after review by the full Commission, denies
compensation benefits relating to such medical condition. Following the entry of a workers’ compensation
award pursuant to clause (i) or (ii) having the effect of prohibiting the application of any such exclusion,
Cigna Healthcare shall immediately provide coverage for such medical condition to the extent otherwise
covered under the contract, subscription contract or health services plan. If, upon appeal to the Court of
Appeals or the Supreme Court, such medical condition is held to be compensable under the Virginia
Workers’ Compensation Act (Title 65.2), Cigna Healthcare may recover from the applicable employer or
workers’ compensation insurance carrier the costs of coverage for medical conditions found to be
compensable under the Act.
10. Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of
nuclear energy when government funds are available for treatment of Illness or Injury arising from such
release of nuclear energy; however, benefits may not be able to be provided or may be delayed in the
event of a major disaster; (c) an Insured Person participating in the military service of any country
(note: for information about an Insured Person who becomes an active duty member of the military, please
see “Cancellation by You” under “Terms of the Policy” in the “General Provisions” section); (d) an Insured
Person participating in an insurrection, rebellion, or riot.
11. Any services provided by a local, state or federal government agency (except Medicaid), except when
payment under this Policy is expressly required by federal or state law.
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12. Any services required by state or federal law to be supplied by a public school system or school district.
13. Any services for which payment may be obtained from any local, state or federal government
agency (except Medicaid). Veterans Administration Hospitals and military treatment facilities, except for
services rendered on an emergency basis where a legal liability exists for charges made to the Insured
Person for such services.
14. If the Insured Person is enrolled in Medicare Part A, B, C or D, Cigna Healthcare will provide claim
payment according to this Policy minus any amount paid by Medicare, not to exceed the amount Cigna
Healthcare would have paid if it were the sole insurance carrier.
15. Court-ordered treatment or hospitalization, unless such treatment is an involuntary hold or prescribed
by a Physician and listed as covered in this Policy.
16. Professional services performed by a member of the Insured Person’s immediate family and services
for which no charge is normally made in the absence of insurance.
17. Supplies received or purchased directly or on your behalf from any of the following:
• Yourself, or a company under your partial or complete ownership;
• A person who is your spouse, Domestic Partner, child, stepchild, parent, brother or sister; or
• A facility or health care professional that provides remuneration to you, directly or indirectly, or to an
organization from which you receive, directly or indirectly, remuneration.
18. Custodial Care, including but not limited to rest cures; infant, child or adult day care, including
geriatric day care. This exclusion does not apply to Hospice Care Services, or Occupational Therapy to
restore activities such as walking, eating, drinking, dressing, toileting, transferring from wheelchair to bed,
bathing, and job related activities.
19. Private duty nursing in the inpatient setting, except when provided as part of the Hospice Care Services
benefit in this Policy.
20. Inpatient room and board charges in connection with a Hospital stay primarily for environmental
change or Physical Therapy.
21. Services received during an inpatient stay when the stay is primarily related to behavioral, social
maladjustment, lack of discipline or other antisocial actions which are not specifically the result of a Mental
Health Disorder.
22. Complementary and alternative medicine services, including but not limited to: massage therapy;
animal therapy, including but not limited to equine therapy or canine therapy; art therapy; meditation;
visualization; acupuncture (this exclusion does not apply to the + Acupuncture plans); acupressure;
acupuncture point injection therapy; reflexology; rolfing; light therapy; aromatherapy; music or sound
therapy; dance therapy; sleep therapy, except as stated in this Policy under “Sleep Testing and Treatment”;
hypnosis; energy-balancing; breathing exercises; movement and/or exercise therapy including but not
limited to yoga, pilates, tai-chi, walking, hiking, swimming, golf; and any other alternative treatment as
defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National
Institutes of Health. Services specifically listed as covered under “Habilitative and Rehabilitative Services”
are not subject to this exclusion.
23. Any services or supplies provided by or at a place for the aged, a nursing home, or any facility where
a significant portion of the activities of which include rest, recreation, leisure, or any other services that are
not Covered Services.
24. Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other
Custodial Care; home care services that are not rendered under an approved arrangement with a home
health care provider; self-care activities or homemaker services; and services primarily for rest, domiciliary
or convalescent care.
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25. Services performed by unlicensed practitioners or services which do not require licensure to perform;
for example, meditation, breathing exercises, guided visualization.
26. 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.
27. Services which are self-directed to a free-standing or Hospital-based diagnostic facility.
28. Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or
treatment to the teeth or gums, except as specifically provided in this Policy under “Oral Surgery” and
“Dental Care.”
29. Orthodontic services, braces and other orthodontic appliances including orthodontic services for
Temporomandibular Joint Dysfunction, except for services as stated in this Policy under “Congenital
Defects and Birth Abnormalities for Newborns.”
30. Dental implants: dental materials implanted into or on bone or soft tissue or any associated procedure as
part of the implantation or removal of dental implants.
31. Any services covered under both this medical plan and an accompanying exchange-certified
pediatric dental plan and reimbursed under the dental plan will not be reimbursed under this plan.
32. Hearing aids including but not limited to semi-implantable hearing devices, audient bone conductors and
Bone Anchored Hearing Aids (BAHAs). For the purposes of this exclusion, a hearing aid is any device that
amplifies sound. This exclusion does not apply to cochlear implants or hearing aids for children 18 years
of age or younger, as stated in this Policy under “Hearing Aids.”
33. Routine hearing tests except as provided under Preventive Care.
34. Genetic screening, except as stated in this Policy under “Pregnancy and Maternity Care” and “Women’s
Preventive Care,” or pre-implantation genetic screening: general population-based genetic screening is a
testing method performed in the absence of any symptoms or any significant, proven risk factors for
genetically linked inheritable disease.
35. Gene Therapy including, but not limited to, the cost of the Gene Therapy product, and any medical,
surgical, professional and facility services directly related to the administration of the Gene Therapy
product.
36. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams,
and routine eye refractions, except as specifically stated in this Policy under Pediatric Vision Care.
37. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as
nearsightedness (myopia), astigmatism and/or farsightedness (presbyopia).
38. Cosmetic surgery, therapy or other services for beautification, to improve or alter appearance or self-
esteem. This exclusion shall not include Reconstructive Surgery when such service is incidental to or
follows surgery resulting from trauma, infection or other diseases of the involved part, and Reconstructive
Surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a
functional defect.
39. Aids or devices that assist with nonverbal communication, including but not limited to communication
boards, prerecorded speech devices, laptop computers, desktop computers, personal digital assistants
(PDAs), braille typewriters, visual alert systems for the deaf and memory books.
40. Non-medical counseling or ancillary services, including but not limited to: education, training,
vocational rehabilitation, behavioral training, biofeedback, neurofeedback, employment counseling, back
school, return to work services, work hardening programs, driving safety, and services, training,
educational therapy or other non-medical ancillary services for learning disabilities and developmental
delays.
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41. Services and procedures for redundant skin surgery including abdominoplasty/panniculectomy, removal
of skin tags, craniosacral/cranial therapy, applied kinesiology, prolotherapy and extracorporeal shock wave
lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, macromastia or gynecomastia, and
blepharoplasty.
42. Any treatment, Prescription Drug, service or supply to treat sexual dysfunction, enhance sexual
performance or increase sexual desire.
43. All services related to the treatment of fertility and/or Infertility, including, but not limited to, all tests,
consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including
reversals of elective sterilization and in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote
intrafallopian transfer (ZIFT), except as specifically stated in this Policy.
44. Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
45. Fees associated with the collection or donation of blood or blood products, except for autologous
donation in anticipation of scheduled services where in the utilization review Physician’s opinion the
likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
46. Blood administration for the purpose of general improvement in physical condition.
47. Orthopedic shoes (except when joined to Braces), shoe inserts, foot Orthotic Devices.
48. Electronic Prosthetic limbs or appliances unless Medically Necessary, when a less-costly alternative
is not sufficient.
49. Prefabricated foot Orthoses.
50. Cranial banding/cranial Orthoses/other similar devices, except when used postoperatively for
synostotic plagiocephaly.
51. Orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers.
52. Orthoses primarily used for cosmetic rather than functional reasons.
53. Non-foot Orthoses, except only the following non-foot Orthoses are covered when Medically Necessary:
• Rigid and semi-rigid custom fabricated Orthoses;
• Semi-rigid pre-fabricated and flexible Orthoses; and
• Rigid pre-fabricated Orthoses, including preparation, fitting and basic additions, such as bars and
joints.
54. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care
which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery,
even if the Insured Person has other health conditions that might be helped by a reduction of obesity or
weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to
treat obesity, weight control or weight reduction. This exclusion does not apply to obesity counseling as a
preventive service for infants, children, and adults.
55. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition. This
includes reports, evaluations, or hospitalization not required for health reasons; physical exams required
for or by an employer or for school, or sports physicals, or for insurance or government authority, and court
ordered, forensic, or custodial evaluations, except as otherwise specifically stated in this Policy.
56. Therapy or treatment intended primarily to improve or maintain general physical condition or for the
purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine,
long term, or maintenance care which is provided after the resolution of the acute medical problem and
when significant therapeutic improvement is not expected. This does not apply to preventive care services,
rehabilitative or Habilitative Services as stated in this Policy.
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57. Educational services except for the treatment of autism or otherwise stated in this Policy under
“Diabetes,” “Mastectomy Notice” regarding lymphedema under “Reconstructive Surgery,” and “Inpatient
Services” under “Mental Health and Substance Use Disorder Services,” or as specifically provided or
arranged by Cigna Healthcare.
58. Nutritional counseling except when provided as part of home health care, treatment of an eating
disorder, or “Diabetic Self-Management Training” or “Preventive Care Services” subsections; or food
supplements except as described in the “Nutritional Formulas” section of this Policy.
59. Exercise equipment, comfort items and other medical supplies and equipment not specifically listed
as Covered Services in the “Comprehensive Benefits: What the Policy Pays For” section of this Policy.
Excluded medical equipment includes, but is not limited to: air purifiers, air conditioners, humidifiers;
treadmills; spas; elevators; supplies for comfort, hygiene or beautification; wigs, disposable sheaths and
supplies; correction appliances or support appliances and supplies such as stockings, and consumable
medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages
and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this
Policy under the “Prescription Drug Benefits” section.
60. Foreign Country Provider charges except as specifically stated under “Foreign Country Providers” in
the section of this Policy titled “Comprehensive Benefits: What the Policy Pays For.”
61. Routine foot care unless Medically Necessary. This exclusion applies to cutting or removing corns and
calluses; trimming nails; cleaning and preventive foot care, including but not limited to:
• Cleaning and soaking the feet.
• Applying skin creams to care for skin tone.
• Other services that are given when there is not an Illness, Injury or symptom involving the foot.
This exclusion does not apply to the treatment of corns, calluses, and care of toenails when these services
are Medically Necessary.
62. Charges for the services of a standby Physician.
63. Charges for animal to human organ transplants.
64. Claims received by Cigna Healthcare after 90 days from the date service was rendered, except (a) in
the event of a legal incapacity or (b) if the claim is received by Cigna Healthcare later than 90 days but as
soon as reasonably possible.
65. Services obtained from a Dedicated Virtual Care Physician that are not Dedicated Virtual Urgent Care
or Dedicated Virtual Primary Care services.
