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Exclusions

LIMITATIONS AND EXCLUSIONS

Some services have limitations. Limitations mean that the service is limited by the amount of the service or the length of the time for the service. Some services are excluded. Excluded services are services that are not covered under the District Care program.

PROGRAM LIMITATIONS AND EXCLUSIONS

  • Aflibercept injection
  • All costs associated with the collection and preservation of sperm for artificial insemination. Fertility or infertility testing, artificial insemination or invitro fertilization, embryo transplantation, human chronic gonadotropin (HCG) injections or reversal of sterilization procedure.
  • Allergy testing and immunotherapy.
  • Alternative and holistic health care services.
  • Ambulance
  • Amniocentesis.
  • Any medical service provided or received outside of Palm Beach County will not be considered for reimbursement by the HCDPBC unless authorized by the Health Care District.
  • Any patient treated in a hospital while under arrest by, in custody of, being guarded by a law enforcement officer, or under house arrest (as an outcome of incarceration and/or sentencing).
  • Any service provided or received without having been prescribed, directed or authorized by the Health Care District.
  • Any services in connection with education and treatment for learning or developmental disabilities.
  • Avastin (ophthalmology)
  • Balloon Sinuplasty procedures;
  • Bone Stimulators.
  • Carpal tunnel surgical procedures.
  • Chelation therapy.
  • Chiropractic treatment or services.
  • Complications related to non-covered services.
  • Cost of services performed in an out-of-network facility without prior authorization.
  • Custodial, domiciliary, convalescent or rest care and care in a skilled nursing facility.
  • Dental services.
  • Diabetic shoes, diabetic shoe inserts or any item related to diabetic footwear.
  • Cosmetic, medical, surgical, and non-surgical treatments and procedures provided primarily for cosmetic purposes, which shall include but are not limited to: (1) surgery to the upper and lower eyelid; (2) penile implant; (3) augmentation mammoplasty; (4) reduction mammoplasty for male or female or other cosmetic procedures to the breast, (5) removal of breast implants, except in post mastectomy surgery; (6) full or partial facelift; (7) dermabrasion or chemical exfoliation; (8) scar revision,(9) otoplasty; (10) surgical lift, stretch, or reduction of the abdomen, buttocks, thighs, or upper arm; (11) silicone injections to any part of the body; (12) rhinoplasty; (13) hair transplant; and (14) tattoo removal.
  • Dialysis for chronic renal failure after the 90th day of treatment from the first day of dialysis treatment; dialysis treatments within the home.
  • ECP (External Counter pulsation).
  • ECT (Electroconvulsive Therapy).
  • Research or Experimental medical, surgical or psychiatric procedures and pharmacological regimes that are not generally accepted by the medical community or the Health Care District. This includes clinical trials.
  • Eyeglasses or contact lenses.
  • Foot care, such as removal of warts, corns, or calluses, including, but not limited to, podiatric treatment of bunions, toenails, flat feet, fallen arches, hammertoes, and chronic foot strain.
  • Gastric stapling, gastric bypass, gastric banding, and other surgical experimental or investigational procedures for the treatment of obesity, weight loss and/or weight management. Diet programs and any variants thereof or exercise programs.
  • Genetic testing, counseling and other related services.
  • Hyalgan injections.
  • Health or beauty aids, or hair analysis.
  • Hearing aids.
  • Hospice
  • Hyperbaric services for wound care.
  • Immunizations required for travel and physical examinations needed for employment, insurance, or governmental licensing.
  • Joint replacements.
  • Neuro-psych services (JFK psych only)
  • Optometry Services.
  • Orthotics (except for joint immobilization or follow-up related to trauma care).
  • Pain management (non-injectable).
  • Pharmaceuticals when a patient assistance program is available.
  • Private duty nursing services.
  • Sclero therapy.
  • Services associated with aiding a patient in the home, such as homemaker, domestic or maid service.
  • Services provided by a family member.
  • Services provided in a hospital setting when the member leaves against medical advice (AMA).
  • Any injury resulted from being arrested by, in custody of, being guarded by a law enforcement officer or under house arrest (as an outcome of incarceration and/or sentencing).
  • Services received prior to your eligibility effective date or after the termination date.
  • Sex change operations or any sex change-related services including services for sexual transformation.
  • Services associated with sexual dysfunction or inadequacies.
  • Spinal fusion, corrective surgery for congenital spinal scoliosis, spinal decompression, spinal stabilization, disc replacement surgery, lumbar spinal fusion, foraminotomy, or discectomy associated with chronic degenerative disc disease or spinal stenosis. Emergency treatment for disc herniation associated with acute spinal cord injury and cauda equina syndrome will be considered on a case by case basis.
  • Transplants and any related service to transplants, including transplant donor expenses, or stem cell transplant.
  • Transportation
  • Travel, whether or not recommended by a physician.
  • Treatment and/or repair of chronic congenital abnormalities.
  • Treatment for acne or non-symptomatic, non-malignant, lesions, which may include but are not limited to warts, moles, nevi, lipomas, or cysts.
  • Treatment for conditions covered by Workers’ Compensation laws.
  • Treatment for military service-connected disabilities for which the Veterans Administration and military hospital system provides care to which the member is legally entitled and when such facilities are reasonably available within the service area.
  • Treatment of Temporomandibular Joint Disease (TMJ).
  • Treatment of varicose veins of the extremities.
  • Unattended sleep studies.
  • Urgent care clinic services.
  • Vision training, eye exercises, orthoptics, or surgery performed primarily to correct or improve myopia, presbyopia, or astigmatism.
  • Wound VAC (Outpatient).

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