What UMP Doesn't Cover
2009 Expenses Not Covered, Exclusions, and Limitations
UMP covers only the services and conditions specifically identified in the Certificate of Coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. If you have questions, call Customer Service at 1-800-762-6004.
Here are some examples of common services and conditions that are not covered. Many others are also not covered—these are examples only, not a complete list. These examples are called "exclusions"; these services are not covered, even if medically necessary.
1. Acupuncture, except as described under "Acupuncture".
2. Air ambulance, if ground ambulance would serve the same purpose (see also exclusion 5).
3. Arthroscopic knee surgery for the diagnosis of osteoarthritis.
4. A service, prescription drug, or item that requires preauthorization, if the preauthorization request is not supported by medical justification from a clinician other than the patient or member of the patient's family and approved by UMP.
5. Cabulance or any other form of nonemergency transportation services.
6. Carotid Intima Media Thickness testing.
7. Certified Registered Nurse First Assistants (CRNFAs): UMP does not pay for services provided by CRNFAs unless the CRNFA's supervising physician (MD or DO) bills for the services. UMP will pay only the physician or clinic; UMP does not accept bills from or pay directly to a CRNFA.
8. Circumcision, unless determined medically necessary for a medical condition.
9. Complications arising directly from bariatric (obesity) surgery that UMP did not pay for (no matter when you had that surgery).
10. Complications directly arising from services that would not be covered by UMP during the current plan year. However, UMP will cover complications arising directly from services that UMP did pay for you in the past.
11. Conditions caused by or arising from acts of war.
12. Cosmetic services or supplies, including drugs and pharmaceuticals. However, UMP does cover:
- Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
- Reconstructive surgery of a congenital anomaly (such as cleft lip or palate) to improve or restore that function.
13. Court-ordered care, unless determined by UMP to be medically necessary and otherwise covered.
14. Custodial care; see definition.
15. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed under "Dental Services."
16. Dietary or food supplements, including but not limited to:
- Herbal supplements, dietary supplements, medicinal foods, and homeopathic drugs.
- Infant or adult dietary formulas, except for treatment of congenital metabolic disorders detected by newborn screening such as phenylketonuria (PKU) when specialized formulas have been established as effective for treatment.
- Minerals.
- Prescription or over-the-counter vitamins (except prenatal vitamins during pregnancy).
17. Dietary programs for any purpose except as stated under "Nutrition Therapy (Medical)".
18. Drugs or medicines not covered by UMP as described in the "Your Prescription Drug Benefit" section.
19. Electron Beam Tomography (EBT), self-referred or prescribed by a provider.
20. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:
- Air conditioners or air purifying systems
- Arch supports
- Convenience items and options
- Exercise equipment
- Sanitary supplies
- Massage devices
- Whirlpools, portable whirlpool pumps, or sauna baths
21. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
22. Experimental or investigational services, supplies, or drugs, except for clinical trials consistent with Medicare coverage criteria.
23. Extracorporeal Shockwave Therapy: Low-energy shock waves focused on a source of pain.
24. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
25. Foot care: Cutting of toenails; non-surgical care for diagnosed corns and calluses; or any other routine foot care.
26. Genetic testing or counseling, except as described under "Genetic Counseling and Testing".
27. Home health care except as described in the Certificate of Coverage.
UMP does not cover the following services:
- 24-hour or full-time care in the home.
- Custodial care.
- Dietary assistance.
- Expenses for normal activities of living such as food, clothing, household supplies, Meals on Wheels, or similar services.
- Services by family members or volunteer workers.
- Services for care that requires preauthorization (when not preauthorized).
28. Hospital inpatient charges such as:
- Admissions solely for diagnostic procedures that could be performed on an outpatient basis.
- Beds "reserved" while the patient is being treated in a special-care unit or is on leave from the hospital.
- Services and devices that do not meet the medical necessity criterion of "the level of service, supply, or intervention recommended for this condition is cost-effective compared to alternative interventions, including no intervention." See additional information under "Hospital Services".
- Personal items (television, special diets not medically necessary to treat the covered condition, or convenience items).
- Private room charges, unless medically necessary and preauthorized by UMP.
29. Immunizations, except those recommended for U.S. residents by the Centers for Disease Control and Prevention's Web site. Immunizations for the purpose of travel or employment, for example, are not covered.
30. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
31. Learning disabilities treatment after diagnosis, with two exceptions: as described under "Physical, Occupational, Speech, and Neurodevelopmental Therapy", or when treating a mental health disorder and covered under the "Mental Health Treatment" benefit.
32. Magnetic Resonance Imaging—Using upright MRIs (uMRI), also known as "positional," "weight-bearing" (partial or full), or "axial loading."
33. Maintenance therapy (see definition).
34. Manipulations of the spine or extremities, except as described under "Spinal and Extremity Manipulations".
35. Massage therapy, unless services meet the criteria in "Massage Therapy." Also, services from massage therapists who are not UMP network providers are not covered.
36.Massage therapy services longer than one hour per session.
37. Medicare-covered services or supplies delivered under a "private contract" with a provider who does not offer services through Medicare, when Medicare is the patient's primary coverage (see ALERT! on page 65 of the UMP 2009 Certificate of Coverage for more information).
- Inpatient programs not solely for treatment of chemical dependency or a mental health condition that requires inpatient treatment (examples include, but are not limited to: schools, wilderness programs, and behavioral programs for adolescents).
- Marital, family, or other counseling or training services, except when provided to treat neuropsychiatric, mental, or personality disorders (see covered services).
- Services from non-PhD psychologists (unless the provider is employed by and delivers services within a licensed community mental health agency, and that agency bills for the services).
40. Non-approved provider types—Services delivered by types of providers not listed as approved, or by providers delivering services outside of the scope of their licenses, are not covered.
41. Non-network provider charges that are above the UMP allowed amount, even when the provider is paid at the out-of-area rate, except when the enrollee has been admitted to the hospital as a result of an emergency room visit and the annual out-of-pocket limit has been met.
42. Organ donor coverage for anyone who is not a UMP enrollee, or costs of locating a donor (such as tissue typing of family members), except as described under "Transplants".
44. Orthoptic therapy, except for strabismus (a specific muscle disorder of the eye). See "Vision Care (Related to Diseases and Disorders of the Eye)".
45. Orthotics (except for diabetics).
46. Panniculectomy or removal of excess skin due to weight loss, even if weight loss was the result of surgery paid for by UMP.
47. Physical exam—Any additional portion of a physical exam beyond what UMP covers under the preventive care benefit, even if required for employment, travel, immigration, licensing, or insurance, and related reports.
48. Physician Assistants (PAs): UMP does not pay for services provided by PAs unless the PA's supervising physician (MD or DO) bills for the services. UMP will pay only the physician or clinic; UMP does not accept bills from or pay directly to a PA.
49. Prescription drug charges over the UMP allowed amount, regardless of where purchased.
50. Provider administrative fees—Any charges for completing forms or copying records, except for records requested by UMP, to perform retrospective utilization review.
53. Replacement of lost, stolen, or damaged durable medical equipment.
54. Replacement of medications that meet any of the following conditions:
- Confiscated or seized by Customs or other authorities.
- Contaminated.
- Damaged.
- Lost or stolen.
- Ruined.
55. Reproductive failure or fertility testing or treatment, including drugs, pharmaceuticals, artificial insemination, and any other type of testing, treatment, or visits for reproductive failure.
56. Residential treatment programs that are not solely for chemical dependency treatment or a mental health condition requiring inpatient treatment (examples include, but are not limited to: schools, wilderness programs, and behavioral programs for teenagers).
57. Reversal of voluntary sterilization (vasectomy or tubal ligation).
- For which no charge is made, or for which a charge would not have been made if you had no health care coverage.
- Provided by a family member.
- That are solely for comfort (and not medically necessary).
- For which you are not obligated to pay.
59. Services performed during a noncovered service.
60. Sexual dysfunction or disorder diagnosis, counseling or treatment (except for penile prostheses, as stated under "Durable Medical Equipment, Supplies, and Prostheses").
61. Sexual reassignment surgery, services, counseling, or supplies.
62. Skilled nursing facility services or confinement:
- For treatment of mental health conditions or mental retardation.
- When primary use of the facility is as a place of residence.
- When treatment is primarily custodial (see "Custodial Care").
63. Temporomandibular joint (TMJ) disorder treatment, except as described in the Certificate of Coverage.
64. Tobacco cessation services, supplies, or medications, except as described under "Tobacco Cessation Program".
65. Transplant expenses not preauthorized by UMP.
66. Weight control, weight loss, and obesity treatment as follows:
- Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. UMP does not cover exercise programs (formal or informal), exercise equipment, or travel expenses associated with non-surgical or surgical services. UMP will not cover such treatment even if prescribed by a provider.
- Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies, unless approved through case management as described under "Obesity Surgery". Removal of excess skin is not covered.
67. Wilderness training programs.
68. Workers' compensation—UMP does not cover services or supplies for work-related illness or injury. Enrollees are responsible for providing UMP with proof from their workers' compensation plan that a claim was rejected before UMP will consider such claims. See Workers' Compensation for information on services that may be covered by workers' compensation.
If you have questions about whether a certain service or supply is covered, call UMP at 1-800-762-6004 (or 425-670-3000 in the Seattle area).
