◦ 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: ◦ 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 133) 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 116 2024 UMP Select (PEBB) Certificate of Coverage