Physician-referred Acupuncture Services We cover physician-referred outpatient visits for acupuncture Services when provided by a Participating Provider when you receive a referral from a Participating Provider, and only when the Services are provided as outpatient Services in the Participating Provider’s office. These Services are subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser. However, you do not need authorization for an initial evaluation and management visit and up to six treatment visits for a New Episode of Care. Acupuncture Services Exclusions  Dermal friction technique.  East Asian massage and tui na.  Laserpuncture.  Nambudripad allergy elimination technique (NAET).  Point injection therapy.  Qi gong.  Services designed to maintain optimal health in the absence of symptoms.  Sonopuncture. 4. Ambulance Services Emergency ground ambulance Services are covered to a Participating Facility, or the nearest facility where care is available. If ground ambulance Services are not appropriate for transporting the Member to the nearest facility, the Plan covers emergency air ambulance. Ambulance Services are covered only when all of the following are true:  A Participating Provider determines that your condition requires the use of medical Services that only a licensed ambulance can provide.  A Participating Provider determines that the use of all other means of transportation, whether or not available, would endanger your health.  The ambulance transports you to or from a location where you receive covered Services. Ambulance Services Exclusions  Transportation by car, taxi, bus, gurney van, wheelchair van, minivan, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Participating Facility or other location. 5. Bariatric Surgery and Weight Control and Obesity Treatment We cover bariatric surgery procedures and related pre-surgery and post-surgery Services for clinically severe obesity in adults, subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser. The Member may request Utilization Review criteria, and a list of the approved surgical procedures we cover when criteria is met, by calling Member Services. In addition to Utilization Review, you must meet one of the following requirements:  The Member fully complies with the Kaiser Permanente Severe Obesity Evaluation and Management Program’s contract for participation approved by Kaiser. EWCLGHDHP1983ACT0124 41 WAPEBB-CD-ACT