Reconstructive Surgery • charges made for reconstructive surgery or therapy to repair or correct a severe physical deformity or disfigurement which is accompanied by functional deficit; (other than abnormalities of the jaw or conditions related to TMJ disorder) provided that: the surgery or therapy restores or improves function; reconstruction is required as a result of Medically Necessary, non-cosmetic surgery; or the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of formation or development) of a body part. Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional improvement as determined by the utilization review Physician.
Coverage is provided as part of a program of treatment when the following criteria are met: • The individual’s condition has the potential to improve or is improving in response to therapy, and maximum improvement is yet to be attained. • There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time. • The therapy is provided by, or under the direct supervision of, a licensed health care professional acting within the scope of the license. • The therapy is Medically Necessary and medically appropriate for the diagnosed condition. Coverage for occupational therapy is provided only for purposes of enabling individuals to perform the activities of daily living after an Injury or Sickness. Therapy services that are not covered include: • sensory integration therapy. • treatment of dyslexia. • maintenance or preventive treatment provided to prevent recurrence or to maintain the patient’s current status. • charges for Chiropractic Care not provided in an office setting. • vitamin therapy. Coverage is administered according to the following: • Multiple therapy services provided on the same day constitute one day of service for each therapy type. • A separate Copayment applies to the services provided by each provider for each therapy type per day.
HC-COV631
12-17
Transplant Services and Related Specialty Care Charges made for human organ and tissue transplant services which include solid organ and bone marrow/stem cell procedures at designated facilities throughout the United States or its territories. This coverage is subject to the following conditions and limitations. Transplant services include the recipient’s medical, surgical and Hospital services; inpatient immunosuppressive medications; and costs for organ or bone marrow/stem cell procurement. Transplant services are covered only if they are required to perform any of the following human to human organ or tissue transplants: allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or intestine which includes small bowel-liver or multi-visceral. Implantation procedures are also covered for artificial heart, percutaneous ventricular assist device (PVAD), extracorporeal membrane oxygenation (ECMO) ventricular assist device (VAD) and intra-aortic balloon pump (IABP) are also covered. • All transplant services and related specialty care services, other than cornea transplants, are covered when received at Cigna LifeSOURCE Transplant Network® facilities. • Transplant services and related specialty care services received at Participating Provider facilities specifically contracted with Cigna for those transplant services and related specialty care services, other than Cigna LifeSOURCE Transplant Network® facilities, are payable at the In-Network level. • Transplant services and related specialty care services received at any other facility, including non-Participating
HC-COV982
01-21
Breast Reconstruction and Breast Prostheses • charges made for reconstructive surgery following a mastectomy; benefits include: surgical services for reconstruction of the breast on which surgery was performed; surgical services for reconstruction of the non- diseased breast to produce symmetrical appearance; postoperative breast prostheses; and mastectomy bras and prosthetics, limited to the lowest cost alternative available that meets prosthetic placement needs. During all stages of mastectomy, treatment of physical complications, including lymphedema therapy, are covered.
myCigna.com
45
Made with FlippingBook - Online magazine maker