2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 131 Section 3 What Medical services are not covered by the plan? Section 3.1 Medical services we do not cover (exclusions) This section tells you what services are “excluded” from Medicare coverage and therefore, are not covered by this plan. The chart below lists services and items that either are not covered under any condition or are covered only under specific conditions. If you get services that are excluded (not covered), you must pay for them yourself, except under the specific conditions listed below. Even if you receive the excluded services at an emergency facility, the excluded services are still not covered and our plan will not pay for them. The only 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 9, Section 5.3 in this document.) Services not covered by Not covered under any Covered only under specific Medicare condition conditions Services considered not Not covered under any reasonable and necessary, condition according to Original Medicare standards. Experimental medical and May be covered by Original surgical procedures, equipment Medicare under a Medicare- and medications. approved clinical research study or by our plan. (See Experimental procedures and Chapter 3, Section 5 for more items are those items and information on clinical research procedures determined by studies.) Original Medicare to not be generally accepted by the medical community. Private room in a hospital. Covered only when medically necessary. Personal items in your room at a Not covered under any hospital or a skilled nursing condition facility, such as a telephone or a television.