◦ Approved by the plan ◦ Supported by medical justification from a clinician other than the member or the member’s family 84. Printing costs for medical records 85. Private duty nursing or continuous care in the member's home, except as described on pages 56 and 68 86. Proton beam therapy for individuals age 21 or older for conditions other than: ◦ Brain/spinal ◦ Skull-based ◦ Esophageal ◦ Other primary cancers where all other ◦ Head/neck treatment options are contraindicated ◦ Hepatocellular carcinoma after review by a multidisciplinary tumor board ◦ Ocular 87. Provider administrative fees: Any charges for completing forms, copying records, or finance charges, except for records requested by the plan to perform retrospective (i.e., post-payment) review 88. Repetitive transcranial magnetic stimulation for tinnitus 89. Replacement of lost, stolen, or damaged durable medical equipment (DME) 90. Replacement of prescription drugs that are any of the following: ◦ Confiscated or seized by Customs or ◦ Expired other authorities ◦ Lost or stolen ◦ Contaminated ◦ Ruined ◦ Damaged 91. Residential treatment programs offered at facilities that do not meet the definition of Residential Treatment Facility (see definition of “Residential treatment facility”) 92. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures) 93. Riot, rebellion, and illegal acts: Services and supplies for treatment of an illness, injury, or condition caused by a member’s voluntary participation in a riot, armed invasion or aggression, insurrection or rebellion, or sustained by a member arising directly from an act deemed illegal by a court of law 94. Routine ultrasounds during pregnancy, except one in week 13 or earlier, one during weeks 13-28, or high-risk pregnancies (see description on page 64) 95. Sacroiliac joint fusion: Minimally invasive and open sacroiliac joint fusion procedures in adults, age 18 or older, with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint disruption 96. Screening and monitoring tests for osteopenia/osteoporosis: ◦ Once treatment for osteoporosis has begun, serial monitoring is not covered ◦ Development of a fragility fracture alone is not a covered indication 97. Separate charges for records or reports 98. Service animals: Any expenses related to a service animal 99. Services covered by other insurance, including, but not limited to: ◦ Automobile no-fault ◦ Commercial premises 2024 UMP Classic (PEBB) Certificate of Coverage 117