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9.13 9.14 9.15 ) developmental disability in which patient management in the dental office has proved to be ineffective; or if the Member has one or more medical conditions that would create significant or undue medical risk for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or ambulatory surgical center. Pre-authorization by AvMed is required. There is no coverage for diagnosis or treatment of dental disease. Home Health Care Services (Skilled Horne Health Care). Home Health Care Services (as defined in Section 2.25) are covered as outlined on the Schedule of Benefits when ordered by and nnder the direction of the Member's Attending Physician. Physical, occupational or speech therapy services provided in the home are limited as noted in Sections 9.27 and 9.31. Home Health Care Services that do not include a medical, diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a registered nurse, licensed practical (vocational) nurse or other healthcare persOImel arc not covered. Homemaker or other Custodial Care services are not covered. ) IIospitaI care: inpatient. All Hospital inpatient services received at Participating Hospitals for non- mental illness or injury are provided when prescribed by your physician and pre-authorized by AvMed. Inpatient services include semi-private room and board, birthing rooms, newborn nursery care, nursing care, meals and special diets when Medically Necessary, use of operating rooms and related facilities, intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests, medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory therapy, and administration of blood or blood plasma. See Section 9.11 with regard to inpatient admission following Emergency Medical Services and Care. - ) Hospital bascd providers will be paid as follows. a) For non-emergency services, the level of payment for Hospital Based Providers who are considered Out-of-Network Providers because they do not contract with A vMed or the plICS Network, will be determined subject to the following criteria: I) If services are performed at an AvMed Choice Network Hospital and the admitting physician is also part of the AvMed Choice Network, then the Hospital Based Provider will be paid at the highest level of benefits. 2) If services are rendered at an A vMed Choice Network Hospital and the admitting physician is not part of the A vMed Choice Network, then the Hospital Based Provider will be paid at the middle level of benefits. 3) If services are rendered at a PHCS Hospital, then the Hospital Based Provider will be paid at the middle level of benefits. 4) If services are rendered at an out-of-network Hospital, then the Hospital Based Provider will be paid at the low level of benefits. Hospice scrvices. Services are available for a Member whose Attending Physician has determincd the Member's illness will result in a remaining life span of 6 months or less. 9.14.01 ) 9.16 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as associated immunosuppressant medications ar~ covered except those deemed experimental. Coverage is limited to the AvMed Choice Network. See Section 11.15. 9.16.01 Transportation benefits for transplant services are administered through Optum Health, an AvMed third party partner. Benefits are limited to $200 per day up to $10,000 lifetime maximum for a companion to accompany the Member (or two companions when the patient is a minor) when the member has to travel greater than a 50 mile radius to receive the transplant. This is a benefit available only when the transplant is authorized at one of AvMed's contracted transplant facilities. 27 A V-CHOlCE-2009 MP-5320 (10/09)