◦ Adrenal ◦ Melanoma ◦ Merkel cell ◦ Breast ◦ Ovarian ◦ Cervical 116. Stereotactic radiation surgery for conditions other than central nervous system primary and metastatic tumors 117. Surrogacy 118. Telephone or virtual consultations or appointments, except as described under “Telemedicine services” on page 75 119. Tinnitus specific therapies including, but not limited to: ◦ Tinnitus retraining therapy (TRT) ◦ Neuromonics tinnitus treatment (NTT) ◦ Tinnitus activities treatment (TAT) ◦ Tinnitus-masking counseling 120. Transcutaneous vagal nerve stimulation (does not include or apply to support of previous implanted VNS) 121. Transcutaneous vagal nerve stimulation for epilepsy or depression 122. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan (see page 42), or approved travel and lodging costs related to the COE Program for single knee and single hip replacement and for spine care 123. Treatment of varicose veins with Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA), Sclerotherapy, and Phlebectomy in patients with pregnancy, active infection, peripheral arterial disease, or deep vein thrombosis (DVT) 124. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading” 125. Vagal nerve stimulation (VNS) for treatment-resistant depression 126. Vagal nerve stimulation (VNS) for the treatment of depression (does not include or apply to support of previously implanted VNS) 127. Vision hardware replacements: ◦ The plan does not cover the replacement of any lost, stolen or broken lenses and/or frames. 128. Vision, routine: ◦ Certain contact lens expenses: • Artistically-painted or nonprescription contact lenses; • Contact lens modification, polishing or cleaning; • Refitting of contact lenses after the initial (90-day) fitting period; • Additional office visits associated with contact lens pathology; and • Contact lens insurance policies or service agreements. ◦ Corrective vision treatment of an experimental or investigational nature 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 115