Coverage restrictions apply to the following conditions/services:

• Airway Obstruction – Limited to obstructions causing sleep apnea and/or dysphagia.
• Baclofen Pump – Limited to medically eligible conditions involving spasticity of the extremities. Requires prior approval with justification from a physician regarding the expected benefits.
• Benign Neoplasm – Limited to neoplasms that cause a functional impairment.
• Burns – Limited to burns that require inpatient hospitalization of at least seven (7) days and/or skin grafting.
• Cyst – Limited to long term cysts that cause significant functional impairment.
• Dental – Limited to the medical diagnosis of Cleft Lip and/or Palate, Seizure Disorder, or Velopharyngeal Incompetency (VPI).
• Craniofacial and Jaw Anomalies – Limited to anomalies that cause a significant functional impairment.
• Diapers/Incontinent Pads – Limited to children over four (4) years of age when necessity is related to an eligible medical condition.
• Ear, Nose, and Throat (ENT) Services - Limited to chronic ear pathology resulting in surgery and/or hearing impairment.
• Eye Diseases and Disorders - Limited to conditions caused by trauma or birth defect. (Myopia and Hyperopia are not covered.)
• Lymphedema – Limited to conditions requiring the use of compression garments and/or surgery.
• Metatarsus Adductus – Limited to conditions requiring surgery, casting or orthosis.
• Neuromyopathies – Limited to non-progressive conditions.
• Orthodontics – Limited to the medical diagnosis of Cleft Lip and/or Palate.
• Scar Revision – Limited to scars that cause a significant functional impairment.
• Varus & Valgus – Limited to conditions requiring casting, bracing, or surgery.
• Tonsillectomy and/or Adenoidectomy – Limited to conditions directly related to eligible ear pathology.