Outpatient Therapy Services Charges for the following therapy services: Cognitive Therapy, Occupational Therapy, Osteopathic Manipulation, Physical Therapy, Pulmonary Rehabilitation, Speech Therapy • Charges for therapy services are covered when provided as part of a program of treatment. Cardiac Rehabilitation • Charges for Phase II cardiac rehabilitation provided on an outpatient basis following diagnosis of a qualifying cardiac condition when Medically Necessary. Phase II is a Hospital- based outpatient program following an inpatient Hospital discharge. The Phase II program must be Physician directed with active treatment and EKG monitoring. Phase III and Phase IV cardiac rehabilitation is not covered. Phase III follows Phase II and is generally conducted at a recreational facility primarily to maintain the patient’s status achieved through Phases I and II. Phase IV is an advancement of Phase III which includes more active participation and weight training. Chiropractic Care Services • Charges for diagnostic and treatment services utilized in an office setting by chiropractic Physicians. Chiropractic treatment includes the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain, and improve function. For these services you have direct access to qualified chiropractic Physicians. Coverage is provided when Medically Necessary in the most medically appropriate setting to: • Restore function (called “rehabilitative”): • To restore function that has been impaired or lost. • To reduce pain as a result of Sickness, Injury, or loss of a body part. • Improve, adapt or attain function (sometimes called “habilitative”): • To improve, adapt or attain function that has been impaired or was never achieved as a result of congenital abnormality (birth defect). • To improve, adapt or attain function that has been impaired or was never achieved because of mental health and substance use disorder conditions. Includes conditions such as autism and intellectual disability, or mental health and substance use disorder conditions that result in a developmental delay.
Services include, but are not limited to: approved surgeries and other therapeutic procedures that have been demonstrated in existing peer-reviewed, evidence-based, scientific literature to have a reasonable likelihood of resulting in pregnancy; laboratory tests; sperm washing or preparation; and diagnostic evaluations. Oral fertility drugs are covered under the Pharmacy benefit. Infertility is defined as: • the inability of opposite-sex partners to achieve conception after at least one year of unprotected intercourse; • the inability of opposite-sex partners to achieve conception after six months of unprotected intercourse, when the female partner trying to conceive is age 35 or older; • the inability of a woman, with or without an opposite-sex partner, to achieve conception after at least six trials of medically supervised artificial insemination over a one-year period; and • the inability of a woman, with or without an opposite-sex partner, to achieve conception after at least three trials of medically supervised artificial insemination over a six- month period of time, when the female partner trying to conceive is age 35 or older. This benefit includes diagnosis and treatment of both male and female infertility. The following are specifically excluded infertility services: • injectable fertility drugs; • assisted reproductive techniques (ART) such as in vitro fertilization (IVF); • reversal of male and female voluntary sterilization; • infertility services when the infertility is caused by or related to voluntary sterilization; • donor charges, donor services, and donor eggs, sperm, and embryos; • services for fertility preservation, including harvesting, cryopreservation, and storage; • pre-implantation genetic material and pre-implantation genetic screening (PGS/PGT-A) of parents/donors beyond what is covered by the medical plan.
HC-COV1467 M
01-25
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