Noblesville Schools Medical Plan 62 Section 2: Exclusions and Limitations Physical Appearance 1. Cosmetic Procedures. See the definition in Section 9: Defined Terms. Examples include: ▪ Pharmacological regimens, nutritional procedures or treatments. ▪ Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures). ▪ Skin abrasion procedures performed as a treatment for acne. ▪ Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple. This exclusion does not apply to liposuction for which Benefits are provided as described under Reconstructive Procedures in Section 1: Covered Health Care Services. ▪ Treatment for skin wrinkles or any treatment to improve the appearance of the skin. ▪ Treatment for spider veins. ▪ Sclerotherapy treatment of veins. ▪ Hair removal or replacement by any means. 2. Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the first breast implant followed mastectomy. See Reconstructive Procedures in Section 1: Covered Health Care Services. 3. Treatment of benign gynecomastia (abnormal breast enlargement in males). 4. Physical conditioning programs such as athletic training, body-building, exercise, fitness, or flexibility. 5. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Procedures and Treatments 1. Removal of hanging skin on any part of the body. Examples include plastic surgery procedures called abdominoplasty and brachioplasty. 2. Medical and surgical treatment of excessive sweating (hyperhidrosis). 3. Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea. 4. Rehabilitation services and Manipulative Treatment to improve general physical conditions that are provided to reduce potential risk factors, where improvement is not expected, including routine, long-term or maintenance/preventive treatment. 5. Habilitative services or therapies for the purpose of general well-being or condition in the absence of a medical or behavioral disabling condition. 6. Physiological treatments and procedures that result in the same therapeutic effects when performed on the same body region during the same visit or office encounter. 7. Biofeedback. 8. The following services for the diagnosis and treatment of TMJ: surface electromyography; Doppler analysis; vibration analysis; computerized mandibular scan or jaw tracking; craniosacral therapy; orthodontics; occlusal adjustment; and dental restorations.