Exclusions and Limitations
For complete detail on any plan’s exclusions and limitations, please read the EOC/COI. Unless exceptions to the
following exclusions are specifically made in EOC/COI for your plan, no benefits are provided for services or
procedures that are:
- Experimental or investigational in nature;
- For or incident to services rendered in the home, or for or incident to hospitalization or confinement in a health
facility primarily for custodial, maintenance or domiciliary care, rest, or to control or change your environment, or to
treat eating disorders such as bulimia, anorexia, etc.;
- Performed in a hospital by hospital officers, residents, interns or others in training;
- For cosmetic surgery or any resulting complications, except that benefits may be provided for medically necessary
services to treat complications of cosmetic surgery (e.g., infections or hemorrhages) upon review and approval by a
Blue Shield physician consultant;
- Incident to an organ transplant;
- For convenience items such as telephones, TVs, guest trays and personal hygiene items;
- For contraceptives and contraceptive devices;
- For or incident to intersex surgery (transsexual operations) except for medically necessary treatment of medical
complications;
- For penile implant devices and surgery, and any related services;
- For routine foot care including callus removal, corn paring or excision, toenail trimming, and treatment (other than
surgery) of chronic conditions of the foot (e.g., weak or fallen arches, flat or pronated foot, pain or cramp of the foot,
bunions, muscle trauma due to exertion or any type of massage procedure on the foot), and for special footwear,
- For or incident to dental care and dental supplies including but not limited to diagnostic, preventive, periodontic and
orthodontic services; dental implants; braces, crowns, dental orthoses and prostheses;
- For substance abuse, or substance abuse treatment or rehabilitation on an inpatient, day-care or outpatient basis;
- For learning disabilities or behavioral problems;
- For or incident to acupuncture;
- For conditions covered by Workers’ Compensation or similar laws;
- Performed by a close relative or by a person who ordinarily resides in the subscriber’s or dependent’s home;
- For or incident to vocational, reading, educational, recreational, art, dance or music therapy, weight control or
exercise programs;
- For eye refractions, surgery to correct refractive error (such as but not limited to radial keratotomy, refractive
keratoplasty), lenses and frames for eye glasses, or contact lenses;