Noblesville Schools Medical Plan 63 Section 2: Exclusions and Limitations 9. Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does not apply to reconstructive jaw surgery when there is a facial skeletal abnormality and associated functional medical impairment. 10. Surgical and non-surgical treatment of obesity. 11. Stand-alone multi-disciplinary tobacco cessation programs. These are programs that usually include health care providers specializing in tobacco cessation and may include a psychologist, social worker or other licensed or certified professionals. The programs usually include intensive psychological support, behavior modification techniques and medications to control cravings. 12. Breast reduction surgery except as coverage is required by the Women's Health and Cancer Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in Section 1: Covered Health Care Services. This exclusion does not apply to breast reduction surgery for treatment of gender dysphoria. 13. Helicobacter pylori (H. pylori) serologic testing. 14. Intracellular micronutrient testing. 15. Cellular and Gene Therapy services not received from a Designated Provider. Providers 1. Services performed by a provider who is a family member by birth or marriage. Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. 2. Services performed by a provider with your same legal address. 3. Services provided at a Freestanding Facility or diagnostic Hospital-based Facility without an order written by a Physician or other provider. Services which are self-directed to a Freestanding Facility or diagnostic Hospital-based Facility. Services ordered by a Physician or other provider who is an employee or representative of a Freestanding Facility or diagnostic Hospital-based Facility, when that Physician or other provider: ▪ Has not been involved in your medical care prior to ordering the service, or ▪ Is not involved in your medical care after the service is received. This exclusion does not apply to mammography. Reproduction 1. Health care services and related expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment.. 2. The following services related to a Gestational Carrier or Surrogate: ▪ Fees for the use of a Gestational Carrier or Surrogate. ▪ Insemination costs of or InVitro fertilization procedures for Surrogate or transfer of an embryo to Gestational Carrier. ▪ Pregnancy services for a Gestational Carrier or Surrogate who is not a Covered Person. 3. Donor, Gestational Carrier or Surrogate administration, agency fees or compensation. 4. The following services related to donor services for donor sperm, ovum (egg cell) or oocytes (eggs), or embryos (fertilized eggs): ▪ Known egg donor (altruistic donation i.e., friend, relative or acquaintance) - The cost of donor eggs. Medical costs related to donor stimulation and egg retrieval. This refers to