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 43; ◦ “Therapy: Habilitative and Rehabilitative” on page 72; ◦ 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 61. Lumbar radiculopathy/sciatica surgery: Minimally invasive procedures that do not include laminectomy, laminotomy, or foraminotomy, including, but not limited to, energy ablation techniques, Automated Percutaneous Lumbar Discectomy (APLD), percutaneous laser, nucleoplasty, etc. 62. Magnetic resonance imaging, (upright) (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading” 63. Maintenance care (see definition on page 178) 64. Manipulations of the spine or extremities, except as described under “Spinal and extremity manipulations” on page 71 65. Marriage, family, or other counseling or training services, except as provided to treat an individual member’s neuropsychiatric, mental health, or substance use disorder 66. Massage therapy services when the massage therapist is not a network provider 67. Medicare-covered services or supplies delivered by a provider who does not offer services through Medicare, when Medicare is the member’s primary coverage 68. Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle 69. Migraine and tension-type headaches: ◦ Treatment of chronic tension-type headache with Botox or acupuncture ◦ Treatment of chronic migraine or chronic tension-type headache with massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (e.g., chiropractic services) Note: For chronic migraines and tension-type headaches, see page 56 70. Missed appointment charges 71. Negative pressure wound therapy in patients with contraindications referred to by the FDA Safety Communication dated February 24, 2011 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 111