when the foot orthosis is for use as a replacement or substitute for missing parts of the foot (e.g. amputated toes) and is necessary for the alleviation or correction of Injury, Sickness or congenital defect; and for persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement. The following are specifically excluded orthoses and orthotic devices: prefabricated foot orthoses; cranial banding and/or cranial orthoses. Other similar devices are excluded except when used postoperatively for synostotic plagiocephaly. When used for this indication, the cranial orthosis will be subject to the limitations and maximums of the External Prosthetic Appliances and Devices benefit; orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers; non-foot orthoses primarily used for cosmetic rather than functional reasons; and non-foot orthoses primarily for improved athletic performance or sports participation. Braces A Brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part. The following braces are specifically excluded: Copes scoliosis braces. Splints A Splint is defined as an appliance for preventing movement of a joint or for the fixation of displaced or movable parts. Coverage for replacement of external prosthetic appliances and devices is limited to the following: replacement due to regular wear. Replacement for damage due to abuse or misuse by the person will not be covered. replacement required because anatomic change has rendered the external prosthetic appliance or device ineffective. Anatomic change includes significant weight gain or loss, atrophy and/or growth. Coverage for replacement is limited as follows: no more than once every 24 months for persons 19 years of age and older; no more than once every 12 months for persons 18 years of age and under;
replacement due to a surgical alteration or revision of the impacted site. The following are specifically excluded external prosthetic appliances and devices: external and internal power enhancements or power controls for prosthetic limbs and terminal devices; and myoelectric prostheses peripheral nerve stimulators.
HC-COV732
01-19
Infertility Services charges made for services related to diagnosis of infertility and treatment of infertility once a condition of infertility has been diagnosed. 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; artificial insemination; and
diagnostic evaluations. 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. However, the following are specifically excluded infertility services: Infertility drugs; In vitro fertilization (IVF); gamete intrafallopian transfer (GIFT); zygote intrafallopian transfer (ZIFT) and variations of these procedures; Reversal of male and female voluntary sterilization; Infertility services when the infertility is caused by or related to voluntary sterilization;
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