◦ Care in any nursing home or convalescent facility ◦ Care provided by a family member 46. Hospital inpatient charges for non-essential services or features, such as: ◦ Admissions solely for diagnostic procedures that could be performed on an outpatient basis ◦ Personal or convenience items ◦ Reserved beds ◦ Services and devices that are not medically necessary (see definition on page 192) 47. Hyperbaric oxygen therapy treatment for: ◦ Acute and chronic sensorineural hearing loss ◦ Brain injury including traumatic (TBI) and chronic brain injury ◦ Cerebral palsy ◦ Migraine or cluster headaches ◦ Multiple sclerosis ◦ Non-healing venous, arterial, and pressure ulcers ◦ Thermal burns 48. Imaging of the sinus for rhinosinusitis using x-ray or ultrasound 49. Immunizations, physical exams and associated services (laboratory or similar tests) for the purpose of travel or employment, even if recommended by the CDC 50. Implantable drug delivery systems (IDDS or infusion pumps) for chronic, non-cancer pain 51. Incarceration: Services and supplies provided while confined in a prison or jail 52. Infertility or fertility testing or treatment after initial diagnosis, including drugs, pharmaceuticals, artificial insemination, and any other type of testing, treatment, complications resulting from such treatment (e.g., selective fetal reduction), or visits for infertility 53. In Vitro Fertilization (IVF) and all related services and supplies, including all procedures involving selection of embryo for implantation 54. Knee arthroplasty: Multi-compartmental arthroplasty and partial knee arthroplasty (including bi- compartmental and bi-unicompartmental) 55. Knee arthroscopy for osteoarthritis of the knee 56. Late fees, finance charges, or collections charges 57. Learning disabilities treatment after diagnosis, except as covered under the following benefits: ◦ “Applied Behavior Analysis (ABA) Therapy” on page 38; ◦ “Therapy: Habilitative and Rehabilitative” on page 74; ◦ When part of treating a mental health disorder; or ◦ When part of treating a substance use disorder. 58. INTENTIONALLY LEFT BLANK. 59. Lumbar artificial disc replacement 60. Lumbar fusion for degenerative disc disease 2024 UMP Classic (PEBB) Certificate of Coverage 115