Orthopedic supplies, except shoes joined to braces Infertility services, family planning, or birth control Services, except as specifically stated in the Evidence of Coverage Form. Reversal of sterilization. In vitro fertilization procedures or artificial insemination, except as specifically stated in the Evidence of Coverage Form. Any related laboratory procedures Air conditioners. Consultations provided by telephone or facsimile machine Custodial cars, rest cures, or any other care provided primarly to meet personal needs, or which does not require continuing Services of medical personnel.
Inpatient stays for environmental change or for physical therapy.
Services provided by a rest home, home for the aged, a nursing home or similar facility. Services received from a skilled nursing facility, except as specifically provided in the Evidence of Coverage Form Treatment of chronic pain except as specifically stated in the Evidence of Coverage Form. Exercise equipment or any charges for activities, instrumentalities, or facilities normally intended or used for developing or maintaining physical fitness Routine physical or psychological examinations for insurance, employment, school, licenses, camp or sports Immunizations for foreign travel. Immunizations other than those recommended by the American Academy of Pediatricians, or the U.S. Public Health Service Acupressure or massage to control pain, treat illness or promote health by applying pressure to one or more specific areas of the body based on dermatoses Eye surgery for refractive defects. Private room, except when authorized by your Primary Care Physician as medically necessary Dental Services or supplies.