R590-249-4. Examples

  The following policy limitation or exclusion examples are not all inclusive:

  (1) charges in connection with reconstructive or plastic surgery that may have limited benefits, such as, a chemical peel that does not alleviate a functional impairment;

  (2) complications relating to services and supplies for, or in connection with, gastric or intestinal bypass, gastric stapling, or other similar surgical procedure to facilitate weight loss, or for, or in connection with, reversal or revision of such procedures, or any direct complications or consequences thereof;

  (3) complications by infection from a cosmetic procedure, except in cases of reconstructive surgery:

  (a) when the service is incidental to or follows a surgery resulting from trauma, infection or other diseases of the involved part; or

  (b) related to a congenital disease or anomaly of a covered dependent child that has resulted in functional defect; or

  (4) complications that result from an injury or illness resulting from active participation in illegal activities.