◦ Sensory movement groups. 2. Air ambulance, if ground ambulance would serve the same purpose 3. Ambulance (all types), to move you to a facility closer to your home or for purposes that are not medically necessary 4. Autologous blood and platelet-rich plasma injections 5. Bariatric surgery under the following circumstances: ◦ BMI 30 to less than 35 without Type II Diabetes Mellitus ◦ BMI less than 30 ◦ Patients younger than 18 years of age 6. Bone growth stimulators for: ◦ Nonunion of skull, vertebrae, or tumor related ◦ Ultrasonic stimulator – delayed fractures and concurrent use with another noninvasive stimulator. 7. Bone morphogenetic protein-7 (rhBMP-7) for use in lumbar fusion 8. Bronchial thermoplasty for asthma 9. Carotid artery stenting of intracranial arteries 10. Carotid intima media thickness testing 11. Catheter ablation for non-reentrant supraventricular tachycardia 12. Cervical spinal fusion without evidence of radiculopathy or myelopathy 13. Complications arising directly from services that would not be covered by the plan during the current plan year. The plan will cover complications arising directly from services that a PEBB plan covered for you in the past. 14. Computed Tomographic Colonography (CTC), also called a virtual colonoscopy, for routine colorectal cancer screening 15. Corneal Refractive Therapy (CRT), also called Orthokeratology 16. Coronary or cardiac artery calcium scoring 17. Cosmetic services or supplies, including drugs and pharmaceuticals, unless part of the following care: ◦ Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury ◦ Reconstructive surgery of a congenital anomaly, such as cleft lip or palate, to improve or restore function 18. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered 19. Custodial care (see definition on page 184) 20. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological treatments for treatment-resistant depression 21. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services (see pages 44–45) 22. Dietary/food supplements, including, but not limited to: ◦ Herbal supplements, dietary supplements, and homeopathic drugs 112 2024 UMP Classic (PEBB) Certificate of Coverage