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), 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 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 are medically
necessary and are covered if performed on an outpatient basis, benefits
are extended for such diagnostic procedures only, but cost-sharing
is 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
• The 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 the TRICARE
Program.
1.1.7 Custodial care as defined in
32
CFR 199.2; also includes Activities of Daily Living (ADL)
as defined in
32 CFR 199.2.
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 is made when the beneficiary or sponsor is not eligible
under the TRICARE Program; or whenever the TRICARE Program is a
secondary payer for claims subject to the Diagnosis Related Group
(DRG) based payment system; or amounts, when combined with the primary
payment, which are 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 the TRICARE
Program, or by Government hospitals serving the general public,
or medical care provided by a Uniformed Service(s) 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 in
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 that require
preauthorization if preauthorization was not obtained. Services
and supplies not provided according to the terms of the preauthorization.
An exception to the preauthorization requirement may be granted
when the services otherwise are 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 as 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 are 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 (e.g., 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 as specifically provided under
32 CFR 199.4(g)(52)(i) and
(ii):
1.1.51.2 A diagnostic or monitoring
procedure which incorporates electronic transmission of data or
remote detection and measurement of a condition, activity, or function
(biotelemetry or remote physiologic monitoring) is not excluded
when:
1.1.51.2.1 The procedure without electronic
transmission of data or biotelemetry is otherwise an explicit or
derived benefit of this section;
1.1.51.2.2 The addition of electronic
transmission of data or biotelemetry to the procedure is medically
necessary and appropriate medical care that improves the efficiency
of the management of a clinical condition in defined circumstances.
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 is cost-shared under
32 CFR 199.5(c)(6). Transportation of an accompanying
medical attendant to ensure the safe transport of the ECHO beneficiary
is also 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 the TRICARE Program. 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 (i.e., Seeing
Eye dogs, hearing/handicap assistance dogs, seizure and other detection
animals, service monkeys) are excluded from coverage under the Basic
or ECHO programs.