QUEST Integration – Exclusions

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA’s QUEST Integration plan excludes benefits for the following services. However, even if excluded, upon request HMSA will review a treatment request or service for medical necessity:

• All medical and surgical procedures, therapies, supplies, drugs and equipment for the treatment of sexual dysfunction or inadequacies
• Ambulance wait time, physician wait time, stand-by services, telephone consultations, telephone calls, writing of prescriptions, stat charges
• Beds – Lounge beds, bead beds, water beds, day beds, overbed tables, bed lifters, bed boards, bed side rails if not an integral part of a hospital bed
• Biofeedback, acupuncture, naturopathic services, faith healing, Christian Science services, hypnosis, massage treatment (by masseurs) and any other form of self-care or self-help training and any related diagnostic testing¹
• Care and treatment for sex and marriage problems, bereavement counseling, weight control, employment counseling, primal therapy, long term character analysis, marathon group therapy, and/or consortium
• Contact lenses for cosmetic purposes; bifocal contact lenses
• Cosmetic services or treatment to improve physical appearance but do not restore or materially improve a bodily function (e.g., hair transplantation, piercing of ears or other body areas, electrolysis, etc.)
• Experimental and/or investigational services, procedures, drugs, devices and treatments. Drugs not approved by the FDA.
• Immunizations for travel or work-related indications
• Non-medical items such as books, telephones, beepers, radios, linens, clothing, television sets, computers, air conditioners, air purifiers, fans, household items, or furnishings
• Organ transplants not meeting the guidelines established by the Medicaid program and organ transplants not specifically identified as benefits
• Orthoptic training
• Oversized lenses, blended or progressive bifocal lenses, tinted or absorptive lenses (except for aphakia, albinism, glaucoma, medical photophobia), trifocal lenses (except as a specific job requirement), spare glasses
• Penile and testicular prostheses and related services
• Personal care items such as shampoos, toothpaste, toothbrushes, mouthwashes, denture cleansers, shoes, slippers, clothing, laundry services, baby oil and powder, sanitary napkins, soaps, lip balm, bandaids
• Physical exams for employment when the patient is self-employed or as a requirement for continuing employment (i.e., truck and taxi drivers’ licensing, other P.E.s as a requirement for continual employment by the State or Federal government, or by private practice)
• Physical exams for travel purposes (foreign or domestic)
• Physical exams, psychological evaluations and/or immunizations as a requirement for Hawaii or other state’s drivers’ licenses or for the purpose of securing life and other insurance policies or plans
• Refractive eye surgery
• Rest cures, custodial care and homemaker services and private duty nursing for adults age 21 and older for members not eligible for long-term services and support (LTSS)
• Reversal of sterilization, in vitro fertilization, artificial insemination, sperm banking procedures, fertilization by artificial means and all procedures and drugs to treat infertility or enhance fertilization
• Routine foot care, treatment of flat feet
• Services provided by a medical professional to a member of his or her immediate family or household for members not eligible for long-term services and support (LTSS). Immediate family is defined as husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild.
• Swimming lessons, summer camp, gym membership, weight control classes and smoking cessation classes
• Topical application of oxygen
• Treatment for obesity, weight loss or weight control programs, food, food supplements including prepared formulas and health foods²
• Treatment of baldness, including hair transplants and topical medications, wigs and hairpieces
• Treatment of complications resulting from previous cosmetic, experimental or investigative services, or other services which are not covered services
• Treatment of Hansen’s Disease after definite diagnosis has been made except for surgical or rehabilitative procedures to restore useful function
• Treatment of persons confined to public institutions
• Treatment of pulmonary tuberculosis when treatment is available at no charge to the general public

COB – Medicare Part D

QUEST Integration will not pay any coinsurance, copayment and/or deductible for prescriptions covered under Medicare Part D.

Notes:

¹ Diabetes education, nutrition classes, prenatal care classes and other self-help classes are not QUEST Integration medical benefits but are available as a community education service to all HMSA QUEST Integration members.

² HMSA’s QUEST Integration plan covers surgical treatment of morbid obesity. Other services performed for weight loss or weight control are not a benefit. If you are treating an obese patient for heart disease, thyroid disease or other medical conditions, be sure to indicate the appropriate medical diagnosis on the claim.

Revision History