67. Medicare-covered services or supplies delivered by a provider who does not offer services through Medicare, when Medicare is the member’s primary coverage 68. Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle 69. Migraine and tension-type headaches: ◦ Treatment of chronic tension-type headache with Botox or acupuncture ◦ Treatment of chronic migraine or chronic tension-type headache with massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (e.g., chiropractic services) Note: For chronic migraines and tension-type headaches, see page 51 70. Missed appointment charges 71. Negative pressure wound therapy in patients with contraindications referred to by the FDA Safety Communication dated February 24, 2011 72. Noncovered provider types: Services delivered by providers not listed as a covered provider type (see page 18) 73. Novocure (i.e., Optune) (tumor treating fields) 74. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye 75. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified on page 48 76. Osteochondral allograft/autograft transplantation for joints other than the knee 77. Out-of-network provider charges that are above the allowed amount 78. Peripheral nerve ablation, using any technique, to treat limb pain for adults and children, including for knee, hip, foot, or shoulder due to osteoarthritis or other conditions 79. Pharmacogenetic testing for patients being treated with oral anticoagulants 80. Pharmacogenomics testing for depression, mood disorders, psychosis, anxiety, attention deficit hyperactivity disorder (ADHD), and substance use disorder 81. Positron Emission Tomography (PET) scans for routine surveillance of lymphoma 82. Prescription drug charges over the allowed amount, regardless of where purchased 83. Prescription drugs that require preauthorization, unless the request is: ◦ Approved by the plan ◦ Supported by medical justification from a clinician other than the member or the member’s family 84. Printing costs for medical records 85. Private duty nursing or continuous care in the member's home, except as described on pages 55 and 67 86. Proton beam therapy for individuals age 21 or older for conditions other than: ◦ Brain/spinal ◦ Ocular ◦ Esophageal ◦ Skull-based ◦ Head/neck ◦ Other primary cancers where all other ◦ Hepatocellular carcinoma treatment options are contraindicated 114 2024 UMP Select (PEBB) Certificate of Coverage