◦ Non-high-risk patients: • Automated Breast Ultrasound (ABUS) • Handheld Ultrasound (HHUS) • Magnetic Resonance Imaging (MRI) ◦ High-risk patients: • Automated breast ultrasound (ABUS) • Handheld Ultrasound (HHUS) • Magnetic Resonance Imaging (MRI) less than 11 months after a prior screening 105. Services, supplies, or drugs related to occupational injury or illness (see page 131) 106. Services, supplies, or items that require preauthorization unless the request is: ◦ Approved by the plan ◦ Supported by medical justification from a clinician other than the member or the family of a member 107. Skilled nursing facility services or confinement: ◦ When primary use of the facility is as a place of residence ◦ When treatment is primarily custodial 108. Sleep apnea diagnosis and treatment as indicated in referenced Medicare national and local coverage determinations 109. Sleep therapy services performed at the following locations are not covered: ◦ Emergency room services ◦ Inpatient hospitalization ◦ Urgent-care facilities 110. Sound therapies for treatment of tinnitus, including, but not limited to: ◦ Masking devices (sound maskers) ◦ Altered auditory stimuli ◦ Auditory attention training 111. Spinal cord stimulation for chronic neuropathic pain 112. Spinal injections, therapeutic (except as described under “Spinal injections” on page 71) of the following types: ◦ Facet injections ◦ Intradiscal injections ◦ Medial branch nerve block injections 113. Spinal surgical procedures known as vertebroplasty, kyphoplasty, and sacroplasty 114. Stem cell therapies for musculoskeletal conditions 115. Stereotactic body radiation therapy for the treatment of primary tumor of the following cancer types: ◦ Bone ◦ Head and neck 114 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage