Common use of Spinal Manipulation Services Clause in Contracts

Spinal Manipulation Services. Benefits are provided for spinal manipulations for the detection and correction by manual or mechanical means of structural imbalance or subluxation resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column. The following are excluded from your coverage: 1. Which are not Medically Necessary as determined by Keystone Health Plan Central’s Medical Director(s) or his/her designee(s); 2. Which are considered by Keystone Health Plan Central to be Investigational, except where otherwise required by law; 3. For any illness or injury which occurs in the course of employment if Benefits or compensation are available or required, in whole or in part, under a workers’ compensation policy and/or any federal, state or local government’s workers’ compensation law or occupational disease law, including but not limited to, the United States Longshoreman’s and Harbor Workers’ Compensation Act as amended from time to time. This exclusion applies whether or not the Member makes a claim for the Benefits or compensation under the applicable workers’ compensation policy/coverage and/or the applicable law; 4. For any illness or injury suffered after the Member’s Effective Date of Coverage which resulted from an act of war, whether declared or undeclared; 5. For services received by veterans and active military personnel at facilities operated by the Veteran’s Administration or by the Department of Defense, unless payment is required by law; 6. Which are received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group; 7. For the cost of Hospital, medical, or other Benefits resulting from accidental bodily injury arising out of a motor vehicle accident, to the extent such Benefits are payable under any medical expense payment provision (by whatever terminology used, including such Benefits mandated by law) of any motor vehicle insurance policy; 8. For items or services paid for by Medicare when Medicare is primary consistent with the Medicare Secondary Payer Laws. This exclusion shall not apply when the Contract Holder is obligated by law to offer the Member the Benefits of this Coverage as primary and the Member so elects this Coverage as primary; 9. For care of conditions that federal, state or local law requires to be treated in a public facility; 10. For court ordered services when not Medically Necessary and/or not a covered Benefit; 11. For any services rendered while in custody of, or incarcerated by any federal, state, territorial, or municipal agency or body, even if the services are provided outside of any such custodial or incarcerating facility or building, unless payment is required by law; 12. Which are not billed by and either performed by or under the supervision of an eligible Provider; 13. For services rendered by a Provider who is a member of the Member’s Immediate Family; 14. For telephone and electronic consultations between a Provider and a Member, including telemedicine services, except for telemedicine services relating to genetic counseling; 15. For charges for failure to keep a scheduled appointment with a Provider, for completion of a claim or insurance form, for obtaining copies of medical records, or for a Member’s decision to cancel a Surgery; 16. For services performed by a Professional Provider enrolled in an education or training program when such services are related to the education or training program, including services performed by a resident Physician under the supervision of a Professional Provider; 17. Which exceed the Allowable Amount; 18. Which are Cost-Sharing Amounts required of the Member under this Coverage; 19. For which a Member would have no legal obligation to pay; 20. For services incurred prior to the Member’s Effective Date of Coverage; 21. For services incurred after the date of termination of the Member’s Coverage except as provided for in this Agreement; 22. For services received by a Member in a country with which United States law prohibits transactions; 23. For Inpatient admissions which are primarily for diagnostic studies or for Inpatient services which could have been safely performed on an Outpatient basis; 24. For prophylactic blood, cord blood or bone marrow storage in the event of an accident or unforeseen Surgery or transplant; 25. For Custodial Care, domiciliary care, residential care, protective and supportive care including educational services, rest cures, convalescent care, or respite care not related to Hospice services; 26. For services related to organ donation where the Member serves as an organ donor to a non-member; 27. For transplant services where human organs were sold rather than donated and for artificial organs; 28. For anesthesia when administered by the assistant to the operating Physician or the attending Physician; 29. For Cosmetic Procedures or services related to Cosmetic Procedures performed primarily to improve the appearance of any portion of the body and from which no significant improvement in the functioning of the bodily part can be expected, except as otherwise required by law. This exclusion does not apply to Cosmetic Procedures or services related to Cosmetic Procedures performed to correct a deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. For purposes of this exclusion, prior Surgery is not considered an accidental injury; 30. For oral Surgery, including surgical extractions of full or partial bony impactions, except as specifically provided in this Agreement; 31. For maintenance therapy services, except as required by law; 32. For physical medicine for work hardening, vocational and prevocational assessment and training, functional capacity evaluations, as well as its use towards enhancement of athletic skills or activities; 33. For occupational therapy for work hardening, vocational and prevocational assessment and training, functional capacity evaluations, as well as its use towards enhancement of athletic skills or activities; 34. For speech therapy for the following conditions: psychosocial speech delay, behavior problems, intellectual disability (except when disorders such as aphasia or dysarthria are present), attention deficit disorder/attention deficit hyperactivity disorder, auditory conceptual dysfunction or conceptual handicap and severe global delay; 35. For all rehabilitative therapy, except as described in the Agreement, including but not limited to play, music, and recreational therapy; 36. For sports medicine treatment or equipment intended primarily to enhance athletic performance; 37. For services or supplies that are considered by Keystone to be Investigational, except routine costs associated with Approved Clinical Trials that have been preauthorized by ▇▇▇▇▇▇▇▇. Routine costs do not include any of the following: a. The Investigational drug, biological product, device, medical treatment or procedure itself. b. The services and supplies provided solely to satisfy data collection and analysis needs and that are not used in the direct Clinical Management of the patient. c. The services and supplies customarily provided by the research sponsors free of charge for any enrollee in the Approved Clinical Trial. d. Member travel expenses; 38. For all dental services rendered after stabilization of a Member in an emergency following an accidental injury, including but not limited to, oral Surgery for replacement teeth, oral prosthetic devices, bridges, or orthodontics; 39. For travel expenses incurred in conjunction with Benefits unless specifically identified as a covered service elsewhere in this Agreement; 40. For the following Mental Health Care/Substance Abuse services: educational testing, evaluation testing, hypnosis, marital therapy, methadone maintenance, intellectual disability services, attention deficit disorder testing, other learning disability testing, and long-term care services provided in extended care and state mental health facilities; 41. For neuropsychological testing (NPT) when done through self-testing, self-scored inventories, and projective techniques testing or when done for educational purposes, screening purposes, patients with stable conditions, occupational exposure to toxic substances, or mental health diagnosis, including substance abuse; 42. For back-up or secondary durable medical equipment, including ventilators and prosthetic appliances, and for durable medical equipment requested specifically for travel purposes, recreational or athletic activities, or when the intended use is primarily outside the home; 43. For replacement of lost or stolen durable medical equipment items, including prosthetic appliances, within the expected useful life of the originally purchased durable medical equipment or for continued repair of durable medical equipment after its useful life has exhausted; 44. For replacement of defective or non-functional durable medical equipment when the equipment is covered under the manufacturer’s warranty; 45. For upgrade or replacement of durable medical equipment when the existing equipment is functional except when there is a change in the health of the member such that the current equipment no longer meets the Member’s medical needs; 46. For durable medical equipment intended for use in a facility (Hospital grade equipment); 47. For home delivery, education and set up charges associated with purchase or rental of durable medical equipment, as such charges are not separately reimbursable and are considered part of the rental or purchase price; 48. For prosthetic appliances dispensed to a patient prior to performance of the procedure that will necessitate the use of the device; 49. For personal hygiene, comfort and/or convenience items such as, but not limited to, air conditioners, humidifiers, air purifiers and filters, physical fitness or exercise equipment, including, but not limited to inversion, tilt, or suspension device or table, radio and television, beauty/▇▇▇▇▇▇ shop services, guest trays, chairlifts, elevators, diapers, deodorants, spa or health club memberships, or any other modification to real or personal property, whether or not recommended by a Provider; 50. For items used as safety devices, and for elastic sleeves (except where otherwise required by law), thermometers, bandages, gauze, dressings, cotton balls, tape, adhesive removers, or alcohol pads. 51. For supportive environmental materials and equipment such as handrails, ramps, telephones, and similar service appliances and devices; 52. For enteral nutrition due to lactose intolerance or other milk allergies; 53. For blenderized baby food, regular shelf food, or special infant formula, except as specified in this Agreement; 54. For all other enteral formulas, nutritional supplements, and other enteral products administered orally or through a tube and provided due to the inability to take adequate calories by regular diet, except where mandated by law and as specifically provided in this Agreement; 55. For immunizations required for travel or employment except as required by law; 56. For routine examination, testing, immunization, treatment and preparation of specialized reports solely for insurance, licensing, or employment including but not limited to pre-marital examinations, physicals for college, camp, sports or travel; 57. For services directly related to the care, filling, removal, or replacement of teeth; orthodontic care; treatment of injuries to or diseases of the teeth, gums or structures directly supporting or attached to the teeth; or for dental implants, except where mandated by law and as specifically provided in this Agreement; 58. For treatment of temporomandibular joint syndrome (TMJ) by any and all means including, but not limited to, Surgery, intra-oral devices, splints, physical medicine, and other therapeutic devices and interventions, except for evaluation to diagnose TMJ and except for treatment of TMJ caused by documented organic disease or physical trauma resulting from an accident; Intra-oral reversible prosthetic devices/appliances are excluded regardless of the cause of TMJ; 59. For Hearing Aids, examinations for the prescription or fitting of Hearing Aids, and all related services; 60. For eyeglasses, refractive lenses (glasses or contact lenses), replacement refractive lenses, and supplies, including but not limited to, refractive lenses prescribed for use with an intra-ocular lens transplant; 61. For vision examinations, except for vision screening related to a medical diagnosis for diagnostic purposes. Vision examinations include, but are not limited to: routine eye exams; prescribing or fitting eyeglasses or contact lenses (except for aphakic patients); and refraction, regardless of whether it results in the prescription of glasses or contact lenses; 62. For surgical procedures performed solely to eliminate the need for or reduce the prescription of corrective vision lenses, including but not limited to corneal Surgery, radial keratotomy and refractive keratoplasty; 63. For Infertility services, except for evaluation to diagnose infertility; 64. For donor services related to assisted fertilization and Infertility; 65. For in vitro fertilization and/or embryo transplants; 66. For procedures to reverse sterilization; 67. For Outpatient oral chemotherapy drugs; 68. For whole blood, blood plasma, or blood components; 69. For routine foot care, unless otherwise mandated by law. Routine foot care involves, but is not limited to, hygiene and preventive maintenance (e.g., cleaning and soaking of feet, use of skin creams to maintain skin tone); treatment of bunions (except capsular or bone Surgery), toe nails (except Surgery for ingrown nails), corns, removal or reduction or warts, calluses, fallen arches, flat feet, weak feet, chronic foot strain, or other foot complaints; 70. For supportive devices of the feet, unless otherwise mandated by law and when not an integral part of a leg brace. Supportive devices of the feet include foot supports, heel supports, shoe inserts, and all foot orthotics, whether custom fabricated or sold as is; 71. For treatment, medicines, devices, or drugs in connection with sexual dysfunction, both male and female; 72. For treatment or procedures leading to or in connection with transsexual Surgery or transgender reassignment Surgery except for sickness or injury resulting from such Surgery or for the surgical treatment of congenital ambiguous genitalia present at birth; 73. For abortions, except when the abortion is necessary to avert the death of the mother and in cases of rape and/or incest; 74. For all prescription and over-the-counter drugs dispensed by a pharmacy or Provider for the Outpatient use of a Member, whether or not billed by a Facility Provider, except for allergy serums and mandated pharmacological agents used for controlling blood sugar and except where otherwise required by law. See your Prescription Drug Rider for a listing of exclusions that apply to your Keystone prescription drug plan; 75. For all prescription and over-the-counter drugs dispensed by a Home Health Care Agency Provider, with the exception of intravenous drugs administered under a treatment plan approved by Keystone Health Plan Central; 76. For surgical operations or treatment of obesity and/or morbid obesity, including but not limited to gastric stapling or balloon procedures; 77. For Inpatient stays to bring about non-surgical weight reduction; 78. For private duty nursing services; 79. For biofeedback; 80. For acupuncture; 81. For newborn deliveries outside the Service Area within twenty-eight (28) days of the expected delivery date. 82. For autopsies or any other services rendered after a Member’s demise; 83. For wigs and other items intended to replace hair loss due to male/female pattern baldness; 84. For non-neonatal circumcisions, unless Medically Necessary; 85. For all types of skin tag removal, regardless of symptoms or signs that might be present, except when the condition of diabetes is present; 86. For any services related to or rendered in connection with a non-covered service, including but not limited to anesthesia, diagnostic services, etc.; 87. For services provided at unapproved sites, school settings, or as part of a Mem

Spinal Manipulation Services. Benefits are provided for spinal manipulations for the detection and correction by manual or mechanical means of structural imbalance or subluxation resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column. The following are excluded from your coverage: 1. Which are not Medically Necessary as determined by Keystone Health Plan Central’s Medical Director(s) or his/her designee(s); 2. Which are considered by Keystone Health Plan Central to be Investigational, except where otherwise required by law; 3. For any illness or injury which occurs in the course of employment if Benefits or compensation are available or required, in whole or in part, under a workers’ compensation policy and/or any federal, state or local government’s workers’ compensation law or occupational disease law, including but not limited to, the United States Longshoreman’s and Harbor Workers’ Compensation Act as amended from time to time. This exclusion applies whether or not the Member makes a claim for the Benefits or compensation under the applicable workers’ compensation policy/coverage and/or the applicable law; 4. For any illness or injury suffered after the Member’s Effective Date of Coverage which resulted from an act of war, whether declared or undeclared; 5. For services received by veterans and active military personnel at facilities operated by the Veteran’s Administration or by the Department of Defense, unless payment is required by law; 6. Which are received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group; 7. For the cost of Hospital, medical, or other Benefits resulting from accidental bodily injury arising out of a motor vehicle accident, to the extent such Benefits are payable under any medical expense payment provision (by whatever terminology used, including such Benefits mandated by law) of any motor vehicle insurance policy; 8. For items or services paid for by Medicare when Medicare is primary consistent with the Medicare Secondary Payer Laws. This exclusion shall not apply when the Contract Holder is obligated by law to offer the Member the Benefits of this Coverage as primary and the Member so elects this Coverage as primary; 9. For care of conditions that federal, state or local law requires to be treated in a public facility; 10. For court ordered services when not Medically Necessary and/or not a covered Benefit; 11. For any services rendered while in custody of, or incarcerated by any federal, state, territorial, or municipal agency or body, even if the services are provided outside of any such custodial or incarcerating facility or building, unless payment is required by law; 12. Which are not billed by and either performed by or under the supervision of an eligible Provider; 13. For services rendered by a Provider who is a member of the Member’s Immediate Family; 14. For telephone and electronic consultations between a Provider and a Member, including telemedicine services, except for telemedicine services relating to genetic counseling; 15. For charges for failure to keep a scheduled appointment with a Provider, for completion of a claim or insurance form, for obtaining copies of medical records, or for a Member’s decision to cancel a Surgery; 16. For services performed by a Professional Provider enrolled in an education or training program when such services are related to the education or training program, including services performed by a resident Physician under the supervision of a Professional Provider; 17. Which exceed the Allowable Amount; 18. Which are Cost-Sharing Amounts required of the Member under this Coverage; 19. For which a Member would have no legal obligation to pay; 20. For services incurred prior to the Member’s Effective Date of Coverage; 21. For services incurred after the date of termination of the Member’s Coverage except as provided for in this Agreement; 22. For services received by a Member in a country with which United States law prohibits transactions; 23. For Inpatient admissions which are primarily for diagnostic studies or for Inpatient services which could have been safely performed on an Outpatient basis; 24. For prophylactic blood, cord blood or bone marrow storage in the event of an accident or unforeseen Surgery or transplant; 25. For Custodial Care, domiciliary care, residential care, protective and supportive care including educational services, rest cures, convalescent care, or respite care not related to Hospice services; 26. For services related to organ donation where the Member serves as an organ donor to a non-member; 27. For transplant services where human organs were sold rather than donated and for artificial organs; 28. For anesthesia when administered by the assistant to the operating Physician or the attending Physician; 29. For Cosmetic Procedures or services related to Cosmetic Procedures performed primarily to improve the appearance of any portion of the body and from which no significant improvement in the functioning of the bodily part can be expected, except as otherwise required by law. This exclusion does not apply to Cosmetic Procedures or services related to Cosmetic Procedures performed to correct a deformity resulting from an otherwise covered sickness, Birth Defect or accidental injury. For purposes of this exclusion, prior Surgery is not considered an accidental injury; 30. For oral Surgery, including surgical extractions of full or partial bony impactions, except as specifically provided in this Agreement; 31. For maintenance therapy services, except as required by law; 32. For physical medicine for work hardening, vocational and prevocational assessment and training, functional capacity evaluations, as well as its use towards enhancement of athletic skills or activities; 33. For occupational therapy for work hardening, vocational and prevocational assessment and training, functional capacity evaluations, as well as its use towards enhancement of athletic skills or activities; 34. For speech therapy for the following conditions: psychosocial speech delay, behavior problems, intellectual disability (except when disorders such as aphasia or dysarthria are present), attention deficit disorder/attention deficit hyperactivity disorder, auditory conceptual dysfunction or conceptual handicap and severe global delay; 35. For all rehabilitative therapy, except as described in the Agreement, including but not limited to play, music, and recreational therapy; 36. For sports medicine treatment or equipment intended primarily to enhance athletic performance; 37. For services or supplies that are considered by Keystone to be Investigational, except routine costs associated with Approved Clinical Trials that have been preauthorized by ▇▇▇▇▇▇▇▇. Routine costs do not include any of the following: a. The Investigational drug, biological product, device, medical treatment or procedure itself. b. The services and supplies provided solely to satisfy data collection and analysis needs and that are not used in the direct Clinical Management of the patient. c. The services and supplies customarily provided by the research sponsors free of charge for any enrollee in the Approved Clinical Trial. d. Member travel expenses; 38. For all dental services rendered after stabilization of a Member in an emergency following an accidental injury, including but not limited to, oral Surgery for replacement teeth, oral prosthetic devices, bridges, or orthodontics; 39. For travel expenses incurred in conjunction with Benefits unless specifically identified as a covered service elsewhere in this Agreement; 40. For the following Mental Health Care/Substance Abuse services: educational testing, evaluation testing, hypnosis, marital therapy, methadone maintenance, intellectual disability services, attention deficit disorder testing, other learning disability testing, and long-term care services provided in extended care and state mental health facilities; 41. For neuropsychological testing (NPT) when done through self-testing, self-scored inventories, and projective techniques testing or when done for educational purposes, screening purposes, patients with stable conditions, occupational exposure to toxic substances, or mental health diagnosis, including substance abuse; 42. For back-up or secondary durable medical equipment, including ventilators and prosthetic appliances, and for durable medical equipment requested specifically for travel purposes, recreational or athletic activities, or when the intended use is primarily outside the home; 43. For replacement of lost or stolen durable medical equipment items, including prosthetic appliances, within the expected useful life of the originally purchased durable medical equipment or for continued repair of durable medical equipment after its useful life has exhausted; 44. For replacement of defective or non-functional durable medical equipment when the equipment is covered under the manufacturer’s warranty; 45. For upgrade or replacement of durable medical equipment when the existing equipment is functional except when there is a change in the health of the member such that the current equipment no longer meets the Member’s medical needs; 46. For durable medical equipment intended for use in a facility (Hospital grade equipment); 47. For home delivery, education and set up charges associated with purchase or rental of durable medical equipment, as such charges are not separately reimbursable reimburseable and are considered part of the rental or purchase price; 48. For prosthetic appliances dispensed to a patient prior to performance of the procedure that will necessitate the use of the device; 49. For personal hygiene, comfort and/or convenience items such as, but not limited to, air conditioners, humidifiers, air purifiers and filters, physical fitness or exercise equipment, including, but not limited to inversion, tilt, or suspension device or table, radio and television, beauty/▇▇▇▇▇▇ shop services, guest trays, chairlifts, elevators, diapers, deodorants, spa or health club memberships, or any other modification to real or personal property, whether or not recommended by a Provider; 50. For items used as safety devices, and for elastic sleeves (except where otherwise required by law), thermometers, bandages, gauze, dressings, cotton balls, tape, adhesive removers, or alcohol pads. 51. For supportive environmental materials and equipment such as handrails, ramps, telephones, and similar service appliances and devices; 52. For enteral nutrition due to lactose intolerance or other milk allergies; 53. For blenderized baby food, regular shelf food, or special infant formula, except as specified in this Agreement; 54. For all other enteral formulas, nutritional supplements, and other enteral products administered orally or through a tube and provided due to the inability to take adequate calories by regular diet, except where mandated by law and as specifically provided in this Agreement; 55. For immunizations required for travel or employment except as required by law; 56. For routine examination, testing, immunization, treatment and preparation of specialized reports solely for insurance, licensing, or employment including but not limited to pre-marital examinations, physicals for college, camp, sports or travel; 57. For services directly related to the care, filling, removal, or replacement of teeth; orthodontic care; treatment of injuries to or diseases of the teeth, gums or structures directly supporting or attached to the teeth; or for dental implants, except where mandated by law and as specifically provided in this Agreement; 58. For treatment of temporomandibular joint syndrome (TMJ) by any and all means including, but not limited to, Surgery, intra-oral devices, splints, physical medicine, and other therapeutic devices and interventions, except for evaluation to diagnose TMJ and except for treatment of TMJ caused by documented organic disease or physical trauma resulting from an accident; Intra-oral reversible prosthetic devices/appliances are excluded regardless of the cause of TMJ; 59. For Hearing Aids, examinations for the prescription or fitting of Hearing Aids, and all related services; 60. For eyeglasses, refractive lenses (glasses or contact lenses), replacement refractive lenses, and supplies, including but not limited to, refractive lenses prescribed for use with an intra-ocular lens transplant; 61. For vision examinations, except for vision screening related to a medical diagnosis for diagnostic purposes. Vision examinations include, but are not limited to: routine eye exams; prescribing or fitting eyeglasses or contact lenses (except for aphakic patients); and refraction, regardless of whether it results in the prescription of glasses or contact lenses; 62. For surgical procedures performed solely to eliminate the need for or reduce the prescription of corrective vision lenses, including but not limited to corneal Surgery, radial keratotomy and refractive keratoplasty; 63. For Infertility services, except for evaluation to diagnose infertility; 64. For donor services related to assisted fertilization and Infertility; 65. For in vitro fertilization and/or embryo transplants; 66. For procedures to reverse sterilization; 67. For Outpatient oral chemotherapy drugs; 68. For whole blood, blood plasma, or blood components; 69. For routine foot care, unless otherwise mandated by law. Routine foot care involves, but is not limited to, hygiene and preventive maintenance (e.g., cleaning and soaking of feet, use of skin creams to maintain skin tone); treatment of bunions (except capsular or bone Surgery), toe nails (except Surgery for ingrown nails), corns, removal or reduction or warts, calluses, fallen arches, flat feet, weak feet, chronic foot strain, or other foot complaints; 70. For supportive devices of the feet, unless otherwise mandated by law and when not an integral part of a leg brace. Supportive devices of the feet include foot supports, heel supports, shoe inserts, and all foot orthotics, whether custom fabricated or sold as is; 71. For treatment, medicines, devices, or drugs in connection with sexual dysfunction, both male and female; 72. For treatment or procedures leading to or in connection with transsexual Surgery or transgender reassignment Surgery except for sickness or injury resulting from such Surgery or for the surgical treatment of congenital ambiguous genitalia present at birth; 73. For abortions, except when the abortion is necessary to avert the death of the mother and in cases of rape and/or incest; 74. For all prescription and over-the-counter drugs dispensed by a pharmacy or Provider for the Outpatient use of a Member, whether or not billed by a Facility Provider, except for allergy serums and mandated pharmacological agents used for controlling blood sugar and except where otherwise required by law. See your Prescription Drug Rider for a listing of exclusions that apply to your Keystone prescription drug plan; 75. For all prescription and over-the-counter drugs dispensed by a Home Health Care Agency Provider, with the exception of intravenous drugs administered under a treatment plan approved by Keystone Health Plan Central; 76. For surgical operations or treatment of obesity and/or morbid obesity, including but not limited to gastric stapling or balloon procedures; 77. For Inpatient stays to bring about non-surgical weight reduction; 78. For private duty nursing services; 79. For biofeedback; 80. For acupuncture; 81. For newborn deliveries outside the Service Area within twenty-eight (28) days of the expected delivery date. 82. For autopsies or any other services rendered after a Member’s demise; 83. For wigs and other items intended to replace hair loss due to male/female pattern baldness; 84. For non-neonatal circumcisions, unless Medically Necessary; 85. For all types of skin tag removal, regardless of symptoms or signs that might be present, except when the condition of diabetes is present; 86. For any services related to or rendered in connection with a non-covered service, including but not limited to anesthesia, diagnostic services, etc.; 87. For services provided at unapproved sites, school settings, or as part of a MemMe