Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

') ) Limitations as outlined in Part X (Limitations of Basic Benefits). See Part XI for Exclusions. Hospital based providers who are considered Out-of-Network Providers because they do not contract with AvMed or the PHCS Network, and who provide services in an outpatient setting, will be paid at the mid-level. 9.27 Physical and occupational therapy. Short-term physical and occupational therapy provided in an outpatient Of home care setting is covered to improve or restore physical functioning following disease, injury or loss of a body part. Impairments, functional limitations and disabilities identified are addressed by the design and implementation of a therapentic intervention tailored to the specific needs of the individual patient. Physical and occupational therapy are covered when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. Therapy performed repetitively to maintain a level of function is not covered. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Coverage of outpatient physical and/or occupational therapy is limited to a combined total 0130 visits per calendar year including evaluations. Physical and occupational therapy are covered for the treatment of Autism Spectrum Disorder subject to Section 9.07. See Schedule of Benefits for Co-payments/Co-insurance and Limitations. 9.26.03 t} 9.28 Prescription medication benefits. Allergy serums and chemotherapy for cancer patients arc covered. Coverage for insulin and other diabetic supplies is described in Section 9.06 above. Other retail prescription medications arc a covered benefit only when the Subscribing Group Contract includes supplemental prescription medication benefits; coverage is subject to the Co-payment/Co-insurancc provisions outlined therein. Prosthetic devices. This Contract provides benefits, when Medically Necessary, for prosthetic devices designed to restore bodily function or replace a physical portion of the body. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. Coverage includes the initial purchase, fitting, or adjustment. Replacement is covered only when Medically Necessary due to a change in bodily configuration. The initial prosthetic device following a covered mastectomy is also covered. Replacement of intraocular lenses is covered only if there is a change in prescription that cannot be accommodated by eyeglasses. All other prosthetic devices are not covered including prosthetic devices for Deluxe, Myo-electric and electronic prosthetic devices. The determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based upon its classification as defined by the Centers for Medicare and Medicaid Services. See Schedule of Benefits for any Co-payments or Limitations. See Part XI for Exclusions. 9.29 ) 9.30 Second medical opinions. The Member is entitled to a second medical opinion when he disputes the appropriat~ness or necessity of a surgical procedure or is subject to a serious injury or illness. 9.30.01 9.30.02 9.30.03 A V-CIlOlCE-2009 MP-5320 (10/09) The Member may obtain a second medical opinion from any participating or non-physician, chosen by the Member. If a Participating Provider is chosen, there is no cost to the Member, other than any applicable Co-insurance. If the Member chooses an Out-of-Network Provider, the Member will be responsible for 40% of the amount of the Maximum Allowable Payment for the second medical opinion. Once a second medical opinion has been rendered, AvMed shall review and determine AvMed's obligations under the Contract and that judgment is controlling. Any treatment the Member obtains that is not authorized by AvMed shall be at the Member's expense. AvMed may limit second medical opinions in connection with a particular diagnosis or treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable over-utilization by the Member. 30