1.1 In addition
to any definitions, requirements, conditions, or limitations enumerated
and described in other sections of this manual, the following specifically
are excluded:
1.1.1 Services
and supplies that are not medically or psychologically necessary
for the diagnosis or treatment of a covered illness (including mental
disorder) or injury or for the diagnosis and treatment of pregnancy
or well-baby care.
1.1.2 X-ray, laboratory, and pathological services
and machine diagnostic tests not related to a specific illness or
injury or a definitive set of symptoms except for cancer screening
allowed under the Preventive Services policy. (See
Chapter 7, Sections 2.1 and
2.2; and TRICARE Operations Manual (TOM)
Chapter 24, Section 6.)
1.1.3 Services and
supplies related to inpatient stays in hospitals or other authorized
institutions above the appropriate level required to provide necessary
medical care.
1.1.4 Services and supplies related to an
inpatient admission primarily to perform diagnostic tests, examinations,
and procedures that could have been and are performed routinely
on an outpatient basis.
Note: If it is
determined that the diagnostic x-ray, laboratory, and pathological
services and machine tests performed during such admission were
medically necessary and would have been covered if performed on
an outpatient basis, benefits may be extended for such diagnostic
procedures only, but cost-sharing will be computed as if performed
on an outpatient basis.
1.1.5 Postpartum inpatient stay of a mother for
purposes of staying with the newborn infant (usually primarily for
the purpose of breast feeding the infant) when the infant (but not
the mother) requires the extended stay; or continued inpatient stay
of a newborn infant primarily for purposes of remaining with the
mother when the mother (but not the newborn infant) requires extended postpartum
inpatient stay.
1.1.6 Therapeutic absences from an inpatient
facility, except when such absences are specifically included in
a treatment plan approved by TRICARE.
1.1.7 Custodial care. The term “custodial care”,
as defined in
32 CFR 199.2,
means treatment or services, regardless of who recommends such treatment
or services or where such treatment or services are provided, that
(a) can be rendered safely and reasonably by a person who is not
medically skilled; or (b) is or are designed mainly to help the
patient with the Activities of Daily Living (ADL). These are also
known as “essentials of daily living” as defined in
32 CFR 199.2.
1.1.8 Domiciliary care. The term “domiciliary
care”, as defined in
32 CFR 199.2,
means care provided to a patient in an institution or homelike environment
because:
• Providing support
for the activities of daily living in the home is not available
or is unsuitable; or
• Members of the patient’s family are
unwilling to provide the care.
1.1.9 Inpatient stays
primarily for rest or rest cures.
1.1.10 Costs of services
and supplies to the extent amounts billed are over the allowed cost
or charge.
1.1.11 Services
or supplies for which the beneficiary or sponsor has no legal obligation
to pay; or for which no charge would be made if the beneficiary
or sponsor was not eligible under TRICARE; or whenever TRICARE is
a secondary payer for claims subject to the Diagnosis Related Group
(DRG) based payment system, amounts, when combined with the primary
payment, which would be in excess of charges (or the amount the
provider is obligated to accept as payment in full, if it is less
than the charges).
1.1.12 Services or
supplies furnished without charge.
1.1.13 Services and
supplies paid for, or eligible for payment, directly or indirectly
by a local, state, or Federal Government, except as provided under
TRICARE, or by Government hospitals serving the general public,
or medical care provided by a Uniformed Service medical care facility,
or benefits provided under title XIX of the Social Security Act
(Medicaid).
Note: This exclusion applies to services and
items provided in accordance with beneficiary’s Individualized Family
Service Plan (IFSP) as required by Part C of the Individuals with
Disabilities Education Act (IDEA), and which are otherwise eligible
under the TRICARE Basic Program or the Extended Care Health Option
(ECHO) but determined not to be “medically or psychologically necessary”
as that term is defined within
32 CFR 199.2.
1.1.14 Services and
supplies provided as a part of or under a scientific or medical
study, grant, or research program.
1.1.15 Unproven drugs,
devices, and medical treatments or procedures (see
Section 2.1).
1.1.16 Services or
supplies provided or prescribed by a sponsor or beneficiary, member
of the beneficiary’s or sponsor’s immediate family, or person living
in the beneficiary’s or sponsor’s household.
1.1.17 Services and
supplies that are (or are eligible to be) payable under another
medical insurance or program, either private or governmental, such
as coverage through employment or Medicare.
1.1.18 Services or
supplies which require preauthorization if preauthorization was
not obtained. Services and supplies which were not provided according
to the terms of the preauthorization. An exception to the requirement
for preauthorization may be granted if the services otherwise would
be payable except for the failure to obtain preauthorization.
1.1.19 Psychoanalysis
or psychotherapy provided to a beneficiary or any member of the immediate
family that is credited towards earning a degree or furtherance
of the education or training of a beneficiary or sponsor, regardless
of diagnosis or symptoms that may be present.
1.1.20 Inpatient stays
primarily to control or detain a runaway child, whether or not admission
is to an authorized institution.
1.1.21 Services or
supplies, including inpatient stays, directed or agreed to by a
court or other governmental agency. However, those services and
supplies (including inpatient stays) that otherwise are medically
or psychologically necessary for the diagnosis or treatment of a
covered condition and that otherwise meet all TRICARE requirements
for coverage are not excluded.
1.1.22 Services and
supplies required as a result of occupational disease or injury
for which any benefits are payable under a worker’s compensation
or similar law, whether or not such benefits have been applied for
or paid; except if benefits provided under such laws are exhausted.
1.1.24 Surgery performed
primarily for psychological reasons (such as psychogenic) (see
Chapter 4, Section 2.1).
1.1.27 Services and
supplies that are not medically necessary and appropriate
for the treatment of obesity, or that are otherwise excluded from
coverage (e.g., unproven or cosmetic procedures).
1.1.28 Services and
supplies related to sex gender change, also referred to as sex reassignment surgery,
are prohibited by Section 1079 of Title 10, United States Code (USC).
This exclusion does not apply to surgery and related medically necessary
services performed to correct ambiguous genitalia which has been
documented to have been present at birth (see
Chapter 4, Sections 15.1,
16.1,
17.1, and
Chapter 7, Sections 1.1 and
1.2).
1.1.29 Sex therapy,
sexual advice, sexual counseling, sex behavior modification, psychotherapy,
or other similar services, and any supplies provided in connection
with therapy for sexual dysfunctions, inadequacies, or paraphilic
disorders (see
Chapter 4, Section 15.1 and
Chapter 7, Section 1.1).
1.1.30 Removal of corns
or calluses or trimming of toenails and other routine podiatry services, except
those required as a result of a diagnosed systemic medical disease
affecting the lower limbs, such as severe diabetes (see
Chapter 8, Section 1.1).
1.1.31 Treatment of
dyslexia.
1.1.33 Noncoital reproductive
procedures including artificial insemination, In Vitro Fertilization (IVF),
gamete intrafallopian transfer and all other such assistive reproductive
technologies. Services and supplies related to artificial insemination
(including semen donors and semen banks), IVF, gamete intrafallopian
transfer and all other noncoital reproductive technologies (see
Chapter 4, Sections 17.1,
18.1 and
Chapter 7, Section 2.3).
1.1.37 Services of
chiropractors and naturopaths whether or not such services would
be eligible for benefits if rendered by an authorized provider (see
Chapter 7, Section 18.5).
1.1.38 Counseling services
that are not medically necessary in the treatment of a diagnosed medical
condition. For example, educational counseling, vocational counseling,
and counseling for socioeconomic purposes, stress management, lifestyle
modification, etc. Services provided by a certified marriage and
family therapist, pastoral counselor or Supervised Mental Health
Counselor (SMHC) in the treatment of a mental disorder are covered
only as specifically provided in
32 CFR 199.6. Services
provided by alcoholism rehabilitation counselors are covered only
when rendered in a TRICARE-authorized treatment setting and only
when the cost of those services is included in the facility’s TRICARE-determined
allowable cost rate.
1.1.39 Acupuncture,
whether used as a therapeutic agent or as an anesthetic.
1.1.40 Hair transplants,
wigs (also referred to as cranial prosthesis), or hairpieces, except
as allowed in accordance with section 744 of the DoD Appropriations
Act for 1981 (see
Chapter 4, Section 2.1 and
Chapter 8, Section 12.1).
1.1.41 Self-help, academic
education or vocational training services and supplies, unless the provisions
of
32 CFR 199.4(b)(1)(v) relating to general
or special education, apply.
1.1.42 Exercise equipment,
spas, whirlpools, hot tubs, swimming pools, health club membership or
other such charges or items (see
Chapter 8, Section 2.1).
1.1.43 General exercise
programs, even if recommended by a physician and regardless of whether or
not rendered by an authorized provider. In addition, passive exercises
and range of motion exercises also are excluded, except when prescribed
by a physician and rendered by a physical therapist concurrent to,
and as an integral part of a comprehensive program of physical therapy
(see
Chapter 7, Sections 18.2 and
18.3).
1.1.44 Services of
an audiologist or speech therapist, except when prescribed by a
physician and rendered as a part of an otherwise covered benefit
or treatment addressed to the physical defect itself and not to
any educational or occupational defect (see
Chapter 7, Sections 7.1 and
8.1).
1.1.47 Prostheses,
other than those determined to be necessary because of significant
conditions resulting from trauma, congenital anomalies, or disease.
All dental prostheses are excluded, except for those specifically
required in connection with otherwise covered orthodontia directly
related to the surgical correction of a cleft palate anomaly (see
Chapter 8, Section 4.1).
1.1.48 Orthopedic shoes,
arch supports, shoe inserts, and other supportive devices for the
feet, including special-ordered, custom-made built-up shoes, or
regular shoes later built up (see
Chapter 8, Sections 3.1 and
11.1).
1.1.50 Hearing aids
or other auditory sensory enhancing devices except as specifically
provided in
32 CFR 199.4(e)(24).
1.1.51 Services or
advice rendered by telephone are excluded, except that a diagnostic
or monitoring procedure which incorporates electronic transmission
of data or remote detection and measurement of a condition, activity,
or function (biotelemetry) is not excluded when:
1.1.51.1 The procedure
without electronic transmission of data or biotelemetry is otherwise
an explicit or derived benefit; and
1.1.51.2 The addition
of electronic transmission of data or biotelemetry to the procedure
is found to be medically necessary and appropriate medical care
which usually improves the efficiency of the management of a clinical
condition in defined circumstances; and
1.1.51.3 That each data
transmission or biotelemetry device incorporated into a procedure
that is otherwise an explicit or derived benefit of this section,
has been classified by the U.S. Food and Drug Administration (FDA),
either separately or as a part of a system, for use consistent with
the defined circumstances in
32 CFR 199.4(g)(52)(ii).
1.1.52 Air conditioners,
humidifiers, dehumidifiers, and purifiers.
1.1.53 Elevators or
chair lifts.
1.1.54 Alterations
to living spaces or permanent features attached thereto, even when
necessary to accommodate installation of covered durable medical
equipment or to facilitate entrance or exit.
1.1.55 Items of clothing
or shoes, even if required by virtue of an allergy.
1.1.56 Food, food substitutes,
vitamins, or other nutritional supplements, including those related to
prenatal care, except as specifically covered (see
Chapter 8, Sections 7.1,
7.2, and
7.3).
1.1.57 Enuretic conditioning
programs.
1.1.59 All camping
even though organized for a specific therapeutic purpose, and even
though offered as a part of an otherwise covered treatment plan
or offered through an approved facility.
1.1.60 Housekeeping,
homemaker, or attendant services, sitter or companion (for exceptions,
see
32 CFR 199.4(e)(19) regarding hospice care)
(see the TRICARE Reimbursement Manual (TRM),
Chapter 11, Sections 1 and
4).
1.1.61 All services
and supplies (including inpatient institutional costs) related to
a noncovered condition or treatment, or provided by an unauthorized
provider.
1.1.62 Personal,
comfort, or convenience items, such as beauty and barber services,
radio, television, and telephone (for exceptions, see
32 CFR 199.4(e)(19) regarding hospice care).
Note: Admission
kits are covered.
1.1.63 Megavitamin
psychiatric therapy, orthomolecular psychiatric therapy.
1.1.64 All transportation
except by ambulance, as specifically provided under
32 CFR 199.4(d) and
(e)(5).
Note: Transportation
of an institutionalized ECHO beneficiary to or from a facility or
institution to receive authorized ECHO services or items may be
cost-shared under
32 CFR 199.5(c)(6). Transportation of an accompanying
medical attendant to ensure the safe transport of the ECHO beneficiary
may also be cost-shared (see
Chapter 9, Section 11.1).
1.1.65 All travel even
though prescribed by a physician and even if its purpose is to obtain
medical care, except as specified in
32 CFR 199.4(a)(6).
1.1.66 Services and
supplies provided by other than a hospital, unless the institution
has been approved specifically by TRICARE. Nursing homes, intermediate
care facilities, halfway houses, homes for the aged, or institutions
of similar purpose are excluded from consideration as approved facilities.
1.1.67 Service animals
(Seeing Eye dogs, hearing/handicap assistance dogs, seizure and
other detection animals, service monkeys, etc.) are excluded from
coverage under the Basic or ECHO programs.