2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 143 · Hypnotherapy, behavior training, sleep therapy, weight programs, educational programs, non- medical self-care or self-help including any self-help physical exercise training, or any related diagnostic testing. · Air conditioners, air purifiers, therapeutic mattress supplies or any other similar devices or appliances. · Vitamins, minerals, nutritional supplements or other similar-type products. · Manipulation under anesthesia, hospitalization or any related services. · Prescription drugs or medicines, including non-legend or proprietary medicine, that don't require a prescription order. · Measurement codes, transcutaneous electrical nerve stimulator (TENS) unit for chronic low back pain and related supplies, assistant at surgery, unattended electrical stimulation, gait training, osteopathic manipulation, foot orthotics, X-rays other than for the spine, infrared and ultraviolet therapy, vertebral axial decompression, and massage not performed by a chiropractor. Routine Acupuncture Services Acupuncture service providers You may visit any acupuncturist for routine acupuncture services. For more information please see Access Your Benefits earlier in this section. Covered services The following services are covered under your additional acupuncture benefit: · Services for diagnosis and treatment to correct body imbalances and conditions such as lower back pain, sprains and strains (such as tennis elbow or sprained ankle), nausea, headaches, menstrual cramps and carpal tunnel syndrome. Please refer to the Medical Benefits Chart above for your copayment or coinsurance amount, annual maximum and number of visits allowed under this plan. Limitations and exclusions The limitations and exclusions below apply to your additional acupuncture benefit: · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Worker’s Compensation programs. · Terms and conditions of coverage not outlined in the Evidence of Coverage. · Diagnostic scanning, including Magnetic Resonance Imaging (MRI) and CAT scans. · Thermography. · Hypnotherapy, behavior training, sleep therapy, weight programs, educational programs, non- medical self-care or self-help including any self-help physical exercise training, or any related diagnostic testing.