The types of ancillary equipment not covered are: ◦ Alerting devices ◦ Assistive listening devices for FM/DM systems, receivers and transmitters ◦ Assistive listening devices for microphone transmitters ◦ Assistive listening devices for TDD machines ◦ Assistive listening devices for telephones ◦ Assistive listening devices for televisions (including amplifiers and caption decoders) ◦ Assistive listening devices for use with cochlear implants ◦ Assistive listening devices, supplies, and accessories not otherwise specified 43. Hip resurfacing 44. Hip surgery for treatment of Femoroacetabular Impingement (FAI) Syndrome 45. Home health care, except as described on page 58. The plan does not cover the following services: ◦ Housekeeping or meal services ◦ 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 179) 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 110 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage