La. Admin. Code tit. 37 § XIII-3137

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-3137 - Exclusions

A. There is no benefit provided for the following:

1. any treatment or care not received from a participating hospital or participating provider;

2. private duty nursing;

3. prescription drugs (outpatient) or over-the-counter medicines. However, outpatient prescriptions may be covered by an additional rider to the LA Health Plan;

4. inpatient treatment or counseling for mental and nervous disorders;

5. care for any condition or injury recognized as a compensable loss through any workers' compensation, occupational disease, or similar law;

6. any disease or injury resulting from a war, declared or not, or resulting from any military duty;

7. any item, service, supply, or care not specifically listed as a benefit under the LA Health Plan;

8. care given by a medical department or clinic run by an insured's employer;

9. hospitalization and related services or care rendered if primarily for diagnostic studies;

10. care of corns, bunions (except capsular or related surgery), callouses, nails of the feet (except surgical removal), flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints related to the feet;

11. admission or continued hospital stay for care not medically required on an inpatient basis;

12. skilled nursing care;

13. eyeglasses, contact lenses, hearing aids, hearing devices, or cochlear implants, and related examinations and services;

14. charges for convenience items during a hospital admission;

15. custodial care, rest cures, or travel expenses, even if recommended for health reasons by a physician;

16. care, supplies, or equipment not medically necessary for the treatment of injury or illness;

17. cosmetic or reconstructive surgery except to restore function of any body area which has been altered by disease, trauma, congenital/developmental anomalies, or previous therapeutic processes;

18. care prescribed and supervised by other than a participating provider;

19. dental care and treatment by a dentists or a health care provider, including dental surgery, dental appliances, dental prostheses such as crowns, bridges, or dentures; implants, orthodontic care, operative restoration of teeth (fillings); dental extractions (except impacted teeth); endontic care; apicoectomies, treatment of dental caries, gingivitis, or periodontal surgery, vestibuloplasties, alveoloplasties, dental procedures involving teeth and their bone or tissue supporting structures; frenulectomy; temporomandibular joint syndrome (TMJ), including related appliances; or other dental procedures. Except for the following treatments which shall be reimbursable at the levels specified in §3133 of this regulation:

a. to correct traumatic injuries which occur while the insured is covered under the LA Health Plan; or

b. to correct congenital defects of a child born under and who remains covered under the LA Health Plan; or

c. for the extraction of impacted teeth after the required waiting period has been met;

20. surgical or medical care for obesity, weight reduction, or dietary control;

21. surgical or medical treatment to modify the sex of an individual or services related to the treatment for impotence or other sexual dysfunctions or inadequacies;

22. professional ambulance service;

23. hair transplants, hair pieces, wigs, wig maintenance, or prescriptions or medications related to hair growth;

24. advice or consultation given by any form of telecommunication;

25. services and supplies which are experimental or investigational in nature;

26. charges for failure to keep a scheduled visit or charges for completion of claim forms; charges for physician or hospital standby services; charges for holiday or overtime rates;

27. outpatient speech, occupational, cardiac rehabilitation, or physical therapy;

28. outpatient use of durable medical equipment;

29. radial keratotomy; and surgery, services, or supplies for the surgical correction of nearsightedness and/or astigmatism;

30. services related to or performed in conjunction with artificial insemination, in vitro fertilization or infertility;

31. biofeedback, recreational, or educational therapy, or other forms of self-care or self-help training and any related diagnostic testing;

32. services for conditions related to austic disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral problems, or mental retardation;

33. charges for treatment of a physical injury resulting from suicide or a suicide attempt, sane or insane;

34. intentionally self-inflicted injury;

35. injuries received while committing a crime.

La. Admin. Code tit. 37, § XIII-3137

Promulgated by the Department of Insurance, Office of the Commissioner, LR 20:1012 (September 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:244-247 of the Insurance Code.