Donor charges and services; Cryopreservation of donor sperm and eggs; and Any experimental, investigational or unproven infertility procedures or therapies.
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. 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 Illness or 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; or 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-COV733
01-19
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 Illness, 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).
HC-COV864
01-20
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
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