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35 <br /> • <br /> Written prior approval is required by the Plan's Medical Services <br /> Department. <br /> 7. The evaluation or treatment of Temporomandibular Joint Syndrome <br /> (VW), or any costs associated with appliance surgery and/or <br /> appliance fittings for the above, except as a result of <br /> significant trauma. Coverage for any of the above will require <br /> prior written approval by the Plan's Medical Services Department. <br /> S. All cosmetic procedures (such as, but not limited to: <br /> gynocomastia treatments, scar revisions, and breast reduction <br /> unless medically necessary) except services incidental to or <br /> • <br /> following surgery resulting from trauma, infection, or other <br /> diseases of the involved part and reconstructive surgery because <br /> of a congenital disease or anomaly of a covered Dependent child <br /> which has resulted in a functional defect. <br /> 9. Health Services not Medically Necessary for the diagnosis and <br /> treatment of an accidental injury or sickness or to maintain the <br /> Member's health. <br /> 10. Experimental or unproven medical, surgical, or psychiatric <br /> procedures and pharmacological regimes, and associated Health <br /> Services, not generally accepted by the Plan's Utilization Review <br /> Committee, taking into consideration the decisions of the American <br /> Medical Association, the Food and Drug Administration, and other <br /> medical/professional groups and associations; including, but not <br /> limited to: Sex Change Operations, Gastric Jejunal Bypass (for <br /> purpose of morbid obesity), silastic Implants, Holiopathic and/or <br /> Megavitamin Therapy. <br /> 11. Organ transplants other than cornea, kidney and bone marrow for <br /> Plan Approved conditions. <br /> 12. Health Services received from a non-participating physician or <br /> 30 <br /> 19312=21161301MBIRMIIM90061 <br />