92. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures) 93. Riot, rebellion, and illegal acts: Services and supplies for treatment of an illness, injury, or condition caused by a member’s voluntary participation in a riot, armed invasion or aggression, insurrection or rebellion, or sustained by a member arising directly from an act deemed illegal by a court of law 94. Routine ultrasounds during pregnancy, except one in week 13 or earlier, one during weeks 13-28, or high-risk pregnancies (see description on page 66) 95. Sacroiliac joint fusion: Minimally invasive and open sacroiliac joint fusion procedures in adults, age 18 or older, with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac joint disruption 96. Screening and monitoring tests for osteopenia/osteoporosis: ◦ Once treatment for osteoporosis has begun, serial monitoring is not covered ◦ Development of a fragility fracture alone is not a covered indication 97. Separate charges for records or reports 98. Service animals: Any expenses related to a service animal 99. Services covered by other insurance, including, but not limited to: ◦ Automobile no-fault ◦ Motor vehicle ◦ Commercial premises ◦ Personal injury protection (PIP) ◦ General no-fault ◦ Renter’s ◦ Homeowner’s ◦ Underinsured or uninsured motorist ◦ Medical payments (Med-Pay) See page 133 for more about how this works. 100. Services delivered by providers or facilities delivering services outside the scope of their licenses 101. Services or supplies: ◦ For which no charge is made, or for which a charge would not have been made if you had no health care coverage ◦ For which you are not obligated to pay ◦ Provided by a resident physician or intern acting in that capacity ◦ Provided by someone in the member’s family or household ◦ That are not medically necessary for the diagnosis and treatment of injury or illness or restoration of physiological functions and are not covered as preventive care. This applies even if services are prescribed, recommended, or approved by your provider. ◦ That are solely for comfort 102. Services performed during a noncovered service 103. Services performed primarily to ensure the success of a noncovered service, including, but not limited to, a hiatal hernia repair done to ensure the success of a noncovered laparoscopic adjustable gastric banding surgery 104. Services supplemental to digital mammography. When performed supplementary to digital mammography for screening purposes for members with or without dense breasts, the following procedures are not covered: 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 113