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 11.1).
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. 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 United States (US) 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 and
7.2).
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) are excluded from coverage under the Basic or ECHO
programs.