54 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 4: Medical Benefits Chart (what is covered and what you pay) exception is if the service is appealed and decided upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 7, Section 5.3, in this document.) Services not Not covered under Covered only under specific covered by any condition conditions Medicare Care in an Covered as described in "Residential intermediate or substance use disorder and mental health residential care treatment" section of the Medical Benefits facility, assisted Chart. living facility, or adult foster home Conception by artificial means, such as in vitro fertilization, zygote intrafallopian Not covered under any transfers, ovum condition transplants, and gamete intrafallopian transfers (except artificial insemination and related services covered by Medicare) Cosmetic surgery or Covered in cases of an accidental injury or procedures for improvement of the functioning of a malformed body member. Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. kp.org