VAINDEPO042023 and VAINDEPO042023-HIX Cigna
1/2024
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.