Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 31 - Regulation 53-Basic Health Insurance Plan Pilot Program › Section XIII-3137 - Exclusions

Current through Register Vol. 50, No. 6, June 20, 2024
A. There is no
				benefit provided for the following:
1. any
				treatment or care not received from a participating hospital or participating
				provider;
2. private duty
				nursing;
3. prescription drugs
				(outpatient) or over-the-counter medicines. However, outpatient prescriptions
				may be covered by an additional rider to the LA Health Plan;
4. inpatient treatment or counseling for
				mental and nervous disorders;
5.
				care for any condition or injury recognized as a compensable loss through any
				workers' compensation, occupational disease, or similar law;
6. any disease or injury resulting from a
				war, declared or not, or resulting from any military duty;
7. any item, service, supply, or care not
				specifically listed as a benefit under the LA Health Plan;
8. care given by a medical department or
				clinic run by an insured's employer;
9. hospitalization and related services or
				care rendered if primarily for diagnostic studies;
10. care of corns, bunions (except capsular
				or related surgery), callouses, nails of the feet (except surgical removal),
				flat feet, fallen arches, weak feet, chronic foot strain or symptomatic
				complaints related to the feet;
11.
				admission or continued hospital stay for care not medically required on an
				inpatient basis;
12. skilled
				nursing care;
13. eyeglasses,
				contact lenses, hearing aids, hearing devices, or cochlear implants, and
				related examinations and services;
14. charges for convenience items during a
				hospital admission;
15. custodial
				care, rest cures, or travel expenses, even if recommended for health reasons by
				a physician;
16. care, supplies, or
				equipment not medically necessary for the treatment of injury or
				illness;
17. cosmetic or
				reconstructive surgery except to restore function of any body area which has
				been altered by disease, trauma, congenital/developmental anomalies, or
				previous therapeutic processes;
18.
				care prescribed and supervised by other than a participating
				provider;
19. dental care and
				treatment by a dentists or a health care provider, including dental surgery,
				dental appliances, dental prostheses such as crowns, bridges, or dentures;
				implants, orthodontic care, operative restoration of teeth (fillings); dental
				extractions (except impacted teeth); endontic care; apicoectomies, treatment of
				dental caries, gingivitis, or periodontal surgery, vestibuloplasties,
				alveoloplasties, dental procedures involving teeth and their bone or tissue
				supporting structures; frenulectomy; temporomandibular joint syndrome (TMJ),
				including related appliances; or other dental procedures. Except for the
				following treatments which shall be reimbursable at the levels specified in
				§3133 of this regulation:
a. to correct traumatic injuries which occur
				while the insured is covered under the LA Health Plan; or
b. to correct congenital defects of a child
				born under and who remains covered under the LA Health Plan; or
c. for the extraction of impacted teeth after
				the required waiting period has been met;
20. surgical or medical care for obesity,
				weight reduction, or dietary control;
21. surgical or medical treatment to modify
				the sex of an individual or services related to the treatment for impotence or
				other sexual dysfunctions or inadequacies;
22. professional ambulance service;
23. hair transplants, hair pieces, wigs, wig
				maintenance, or prescriptions or medications related to hair growth;
24. advice or consultation given by any form
				of telecommunication;
25. services
				and supplies which are experimental or investigational in nature;
26. charges for failure to keep a scheduled
				visit or charges for completion of claim forms; charges for physician or
				hospital standby services; charges for holiday or overtime rates;
27. outpatient speech, occupational, cardiac
				rehabilitation, or physical therapy;
28. outpatient use of durable medical
				equipment;
29. radial keratotomy;
				and surgery, services, or supplies for the surgical correction of
				nearsightedness and/or astigmatism;
30. services related to or performed in
				conjunction with artificial insemination, in vitro fertilization or
				infertility;
31. biofeedback,
				recreational, or educational therapy, or other forms of self-care or self-help
				training and any related diagnostic testing;
32. services for conditions related to austic
				disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral
				problems, or mental retardation;
33. charges for treatment of a physical
				injury resulting from suicide or a suicide attempt, sane or insane;
34. intentionally self-inflicted
				injury;
35. injuries received while
				committing a crime.