Citi Benefits Handbook
Exclusions and Limitations
There are services and expenses that are not covered under the non-HMO/PPO plans. The following list of exclusions and limitations applies to your plan benefits unless otherwise provided under your HMO:
  • Ambulance services, when used as routine transportation to receive inpatient or outpatient services;
    • Aetna: Any charges in excess of the benefit, dollar, day, visit or supply limits unless specified otherwise. This includes charges for a service or supply furnished by an in-network provider in excess of the negotiated charge, and charges for a service or supply furnished by an out-of-network provider in excess of the maximum allowed amount or recognized charge. Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the plan are excluded. Charges submitted for services by an unlicensed hospital, physician, or other provider or not within the scope of the provider's license are excluded;
  • Any service in connection with, or required by, a procedure or benefit not covered by the plan;
  • Any services or supplies that are not medically necessary, as determined by the Claims Administrator;
  • BEAM (brain electrical activity mapping) neurologic testing;
    • Oxford: Oxford will provide coverage for magnetoencephalography and magnetic source imaging as outlined in the guidelines below.
      • Magnetoencephalography and magnetic source imaging (MEG/MSI) are considered to be medically necessary for presurgical evaluation in patients with intractable focal epilepsy and presurgical evaluation of brain tumors and vascular malformations
      • Magnetoencephalography and magnetic source imaging (MEG/MSI) are not considered to be medically necessary for the evaluation of brain function in patients with trauma, stroke, learning disorders, or other neurologic disorders and psychiatric conditions such as schizophrenia.
    • There is insufficient evidence to conclude that the use of MEG/MSI improves health outcomes such as improved diagnostic accuracy and treatment planning for patients with trauma, stroke, learning disorders, or other neurologic disorders and psychiatric conditions. Further clinical trials demonstrating the clinical usefulness of this procedure are necessary before it can be considered proven to have a benefit on health outcomes for these conditions.
  • Biofeedback, except as specifically approved by the Claims Administrator;
  • Blood, blood plasma and blood derivatives other than those described under "Covered Services and Supplies." Oxford: Synthetic blood, apheresis or plasmapheresis, the collection and storage of blood, and the cost of securing the services of blood donors are not covered;
  • Breast augmentation and otoplasties, including treatment of gynecomastia. Reduction mammoplasty is not covered unless medically appropriate, as determined by the Claims Administrator;
  • Charges for canceled office visits or missed appointments; boutique, access, or concierge fees to doctors;
  • Care for conditions that, by state or local law, must be treated in a public facility, including mental illness commitments.
  • Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury;
  • Charges made by a hospital for confinement in a special area of the hospital that provides non-acute care, by whatever name called, including, but not limited to, the type of care given by the facilities listed below:
    • Adult or child day care center;
    • Ambulatory surgical center;
    • Birth center;
    • Halfway house;
    • Hospice;
    • Skilled nursing facility;
    • Treatment center;
    • Vocational rehabilitation center; and
    • Any other area of a hospital that renders services on an inpatient basis for other than acute care of sick, or injured persons, or pregnant women. If that type of facility is otherwise covered under the plan, then benefits for that covered facility, which is part of a hospital, as defined, are payable at the coverage level for that facility, not at the coverage level for a hospital;
  • Over the counter contraceptive supplies including but not limited to condoms, contraceptive foams, jellies and ointments;
  • Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem. Cosmetic procedures including, but not limited to, pharmacological regimens, nutritional procedures or treatments, plastic surgery, salabrasion, chemosurgery, and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes, and/or that are performed as a treatment for acne. However, the plan covers reconstructive surgery as described under "Covered Services and Supplies";
  • Court-ordered services and services required by court order as a condition of parole or probation, unless medically appropriate and provided by participating providers upon referral from your PCP (no referral required for Aetna, Anthem BlueCross BlueShield, or Oxford);
  • Coverage for an otherwise eligible person or a dependent who is on active military duty, including health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country;
  • Custodial care made up of services and supplies that meets one of the following conditions:
    • Care furnished mainly to train or assist in personal hygiene or other activities of daily living, rather than to provide medical treatment; or
    • Care that can safely and adequately be provided by persons who do not have the technical skills of a health care professional;
  • Care that meets one of the above conditions is custodial care regardless of any of the following:
    • Who recommends, provides, or directs the care;
    • Where the care is provided; and
    • Whether or not the patient or another caregiver can be or is being trained to care for himself or herself;
  • Dental care or treatment of injuries or diseases to the mouth, teeth, gums, or supporting structures such as, but not limited to, periodontal treatment, endodontic services, extractions, implants, and non-surgical treatments to alter bite or the alignment or operation of the jaw, including treatment of malocclusion or devices to alter bite or alignment. See "Covered Services and Supplies" for limited coverage of oral surgery and dental services;
  • Devices used specifically as safety items or to affect performance primarily in sports-related activities; all expenses related to physical conditioning programs, such as athletic training, body-building, exercise, fitness, flexibility, and diversion or general motivation;
  • Ecological or environmental medicine, diagnosis, and/or treatment;
  • Educational services, special education, remedial education, or job training. The plan does not cover evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, or cognitive rehabilitation. Services, treatment, and educational testing and training related to behavioral (conduct, including impulse control disorders such as pathological gambling, kleptomania, pedophilia, caffeine or nicotine use) problems and learning disabilities are not covered by the plan; See "Covered Services and Supplies" for limited coverage of cognitive services.
  • Education, training, and bed and board while confined in an institution that is mainly a school or other institution for training, a place of rest, a place for the aged, or a nursing home;
  • Enteral feedings and other nutritional and electrolyte supplements, unless it is the sole source of sustenance;
  • Expenses charged by interns, residents, house physicians or other health care professionals who are employed by the covered facility, which marks their services available.
  • Expenses that are the legal responsibility of a third-party payer, such as Workers' Compensation or as a result of a claim;
  • Expenses incurred by a dependent if the dependent is covered as an employee, under the plan for the same services;
  • Experimental, investigational, or unproven services and procedures; ineffective surgical, medical, psychiatric, or dental treatments or procedures; research studies; or other experimental or investigational health care procedures or pharmacological regimes, as determined by the Claims Administrator, unless approved by the Claims Administrator in advance. This exclusion will not apply to drugs:
    • That have been granted investigational new drug (IND) treatment or Group treatment IND status;
    • That are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute;
    • That the Claims Administrator has determined, based on scientific evidence, demonstrate effectiveness or show promise of being effective for the disease. See the Glossary section for the definition of experimental, investigational or unproven services;
  • Eyeglasses and contact lenses (Anthem BlueCross BlueShield and Oxford will cover eyeglasses or contact lenses within 12 months following cataract surgery);
  • False teeth;
  • Aetna: Any treatment, device, drug, service or supply (including surgical procedures, devices to stimulate growth and growth hormones), solely to increase or decrease height or alter the rate of growth;
  • Hair analysis;
  • Hair transplants, hair weaving, or any drug used in connection with baldness. Wigs and hairpieces are not covered unless the hair loss is due to chemotherapy or radiation therapy. Wigs and hairpieces needed for endocrine, metabolic diseases, psychological disorders (such as stress or depression), burns, or acute traumatic scalp injury associated with hair loss must be evaluated and preauthorized by the Claims Administrator;
  • Health services, including those related to pregnancy, that are provided before your coverage is effective or after your coverage has been terminated;
  • Aetna: Hearing services or supplies that do not meet professionally accepted standards; hearing exams given during a stay in a hospital or other facility; replacement parts or repairs for a hearing aid; and any tests, appliance, and devices for the improvement of hearing or to enhance other forms of communication to compensate for hearing loss or devices that stimulate speech, except as described under "Covered Services and Supplies";
  • Herbal medicine, holistic, or homeopathic care, including drugs;
    • Aetna: Not covered; however, discounts are available through the Aetna Natural Products and Services Discount Program;
    • Anthem BlueCross BlueShield: Not covered; however, discounts on alternative medicine and treatment are available through the Anthem Special Offers Program. Log in to Anthem's website at www.anthem.com and click on "Discounts" for information about the Anthem Special Offers Program;
    • Oxford: Not covered; however, discounts are available for some services under the Oxford Healthy Bonus Program;
  • Household equipment including, but not limited to, the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, equipment or supplies to aid sleeping or sitting, removal from your home, worksite or other environment of carpeting, hypo-allergenic pillows, mattresses, paint, mold, asbestos, fiberglass, dust, pet dander, pests or other sources of allergies or illness are not covered. Improvements to your home or place of work, including, but not limited to, ramps, elevators, handrails, stair glides, and swimming pools, are not covered;
  • Hypnotherapy, except when approved in advance by the Claims Administrator;
  • Implantable drugs (other than contraceptive implants);
  • Infertility services, except as described under "Covered Services and Supplies." The plan does not cover charges for the freezing and storage of cryopreserved embryos and charges for storage of sperm or surrogate mothers or any charges associated with them.
    • Anthem BlueCross BlueShield: Cryopreservation of mature oocytes is considered medically necessary in post-pubertal females facing anticipated infertility resulting from chemotherapy or radiation therapy.
  • Aetna's exclusions and limitations on infertility services includes:
    • Infertility services for a female attempting to become pregnant who has not had at least 1 year or more of timed, unprotected coitus, or 12 cycles of artificial insemination (for covered persons under 35 years of age), or 6 months or more of timed, unprotected coitus, or 6 cycles of artificial insemination (for covered persons 35 years of age or older) prior to enrolling in the infertility program;
    • Infertility services for couples in which 1 of the partners has had a previous sterilization procedure, with or without surgical reversal;
    • Reversal of sterilization surgery;
    • Infertility services for females with FSH levels 19 or greater mIU/ml on day 3 of the menstrual cycle;
    • The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier;
    • Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g., office, hospital, ultrasounds, laboratory tests, etc.), unless cryopreservation of mature oocytes or embryos is considered medically necessary for use in IVF/ICSI cycles, and for use in women facing infertility due to chemotherapy, pelvic radiotherapy, or other gonadotoxic therapies with no storage time limitation.
    • Home ovulation prediction kits;
    • Drugs related to the treatment of non-covered benefits;
    • Injectable infertility medications, including but not limited to, menotropins, hCG, GnRH agonists, and IVIG;
    • Any services or supplies provided without pre-certification from Aetna's infertility case management unit;
    • Infertility Services that are not reasonably likely to result in success;
    • Ovulation induction and intrauterine insemination services if you are not infertile.
  • Inpatient private-duty or special nursing care. Outpatient private-duty nursing services must be preauthorized by the Claims Administrator
  • Membership costs for health clubs, personal trainers, massages, weight loss clinics, and similar programs; (Oxford Health Plans offers a $200 reimbursement every six months for employees who can prove they have had 50 gym visits in that time period and $100 every six months for spouses who can prove they have had 50 gym visits in that time period).
  • Naturopathy;
  • Nutritional counseling and nutritionists except as described under "Covered Services and Supplies";
  • Occupational injury or sickness. An occupational injury or sickness is an injury or sickness that is covered under a Workers' Compensation act or similar law. For persons for whom coverage under a Workers' Compensation act or similar law is optional because they could elect it, or could have it elected for them, occupational injury or sickness includes any injury or sickness that would have been covered under the Workers' Compensation act or similar law had that coverage been elected;
  • Outpatient supplies, including, but not limited to, outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic garments, support hose, bedpans, splints, braces, compresses, reagent strips and other devices not intended for reuse by another patient; contact your plan for details. (These may not always be excluded.);
  • Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services;
  • Physical, psychiatric, or psychological exams, testing, or treatments not otherwise covered, when such services are:
    • For purposes of obtaining, maintaining, or otherwise relating to career, education, sports or camp, travel, employment, insurance, marriage, or adoption;
    • Relating to judicial or administrative proceedings or orders;
    • Conducted for purposes of medical research; or
    • To obtain or maintain a license of any type;
  • Radial keratotomy or any other related procedures designed to surgically correct refractive errors, such as LASIK, PRK, or ALK;
  • Recreational, educational, and sleep therapy, including any related diagnostic testing;
    • Oxford: Sleep therapy covered when medically necessary
  • Religious, marital, family, career, social adjustment, pastoral, financial, and sex counseling, including related services and treatment;
  • Reversal of voluntary sterilizations, including related follow-up care;
  • Routine hand and foot care services, including routine reduction of nails, calluses, and corns;
  • Services not covered by the plan;
  • Services or supplies covered by any automobile insurance policy, up to the policy's amount of coverage limitation;
  • Services provided by your close relative (your spouse, child, brother, sister, or your or your spouse's parent or grandparent) for which, in the absence of coverage, no charge would be made;
  • Services given by volunteers or persons who do not normally charge for their services;
  • Services required by a third party including, but not limited to, physical exams and diagnostic services in connection with:
    • Obtaining or continuing employment;
    • Obtaining or maintaining any license issued by a municipality, state, or federal government;
    • Securing insurance coverage;
    • Travel; and
    • School admissions or attendance, including exams required to participate in athletics unless the service is considered to be part of an appropriate schedule of wellness services;
  • Services you are not legally obligated to pay for in the absence of this coverage;
  • Services for, or related to, the removal of an organ or tissue from a person for transplantation into another person, unless the transplant recipient is a covered person under the plan and is undergoing a covered transplant. Services for, or related to, transplants involving mechanical or animal organs are not covered;
  • Special education, including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired to function without that ability;
  • Special medical reports, including those not directly related to the medical treatment of a plan participant (such as employment or insurance physicals) and reports prepared in connection with litigation;
  • Specific non-standard allergy services and supplies, including, but not limited to:
    • Skin titration (Rinkle method);
    • Cytotoxicity testing (Bryan's Test);
    • Treatment of non-specific candida sensitivity;
    • Urine autoinjections;
  • Stand-by services: Boutique, concierge, or on-call fees required by a physician;
  • Surgical operations, procedures, or treatment of obesity, except when approved in advance by the Claims Administrator;
  • Telephone consultations;
    • Aetna: Covered through Teladoc
    • Anthem: Covered through LiveHealth Online
    • Oxford: Telemedicine recognized by Medicare and Medicaid Services are covered when submitted with correct coding.
  • Therapy or rehabilitation including, but not limited to:
    • Primal therapy;
    • Chelation therapy (except to treat heavy metal poisoning);
    • Rolfing;
    • Psychodrama;
    • Recreational;
    • Deep Sleep therapy;
    • Thermograms and thermography;
    • Megavitamin therapy;
    • Purging;
    • Bioenergetic therapy;
    • Vision perception training, except when medically necessary; and
    • Carbon dioxide therapy;
  • Thermograms and thermography;
  • Treatment in a federal, state, or governmental facility, including care and treatment provided in a non-participating hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws;
  • Treatment of injuries sustained while committing a felony or an assault or during a riot or insurrection;
  • Treatment of diseases, injuries, or disabilities related to military service for which you are entitled to receive treatment at government facilities that are reasonably available to you;
  • Treatment, including therapy, supplies, and counseling, for sexual dysfunctions or inadequacies that do not have a physiological or organic basis;
  • Treatment of spinal disorder, including care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or dislocation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of, or related to, distortion, misalignment, or dislocation of or in the vertebral column; and
  • Weight reduction or control (unless there is a diagnosis of morbid obesity), special foods/nutritional supplements, liquid diets, diet plans, or any related products. Aetna: Any food item, including infant formulas, nutritional supplements, vitamins, including prescription vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition.