Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

) 9.31 Speech therapy. Speech therapy provided in the outpatient setting, including the home, is covered only when existing speech function has been impaired by a disease or injury and there is a reasonable expectation that improvement or restoration of speech function can be attained: Non-organic/functional disorders, which are considered speech and language problems with no identifiable medical canse, are not covered, except for the initial evaluation to determine the root cause. Coverage is limited to 24 visits per calendar year including evaluations. Speech therapy is covered for the treatment of Autism Spectrum Disorder subject to Section 9.07. See Schednle of Benefits for Co-payments/Co-insurance and Limitations. ') 9.32 Spinal manipulations will be covered only when Medically Necessary subject to Sections 2.36 and 2.60. No prior referral is required for these services. 9.33 Supplies. Ostomy, urostomy and wound care supplies are covered when Medically Necessary. Items which are not medical supplies or which could be used by the Member or a family member for purposes other than ostomy care are not covered. Wound care supplies are covered as part of an approved treatment plan, when one of the following criteria is met: - ) 9.33.01 9.33.02 9.33.03 treatment of a wound caused by, or treated by, a surgical procedure; or treatment of a wound that required debridement. Provision of ostomy and urostomy supplies are limited to a one-month supply every 30 days. Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and Co- Insurance. 9.34 Urgent Care services. All necessary and covered services received in Urgent Care or Immediate Care Centers or rendered in your Primary Care Physician's office after-hours for conditions as described in Section 2.57 will be covered by AvMed. See Schedule of Benefits for details. In addition, any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Claimant was legally incapacitated. 9.35 Ventilator dependent care. With prior authorization by AvMed, ventilator dependent care (See Section 2.60) is covered up to a total of 100 days lifetime maximum benefit. ) X. LIMITATIONS OF BASIC BENEFITS The rights of Members and obligations of Participating Providers hereunder are subject to the following Limitations: 10.0 I Cardiac rehabilitation. Coverage is limited to the number of visits or the dollar limit listed in the Schedule of benefits, whichever is exhausted first. 10.02 Diagnosis and treatment of Autism Spectrum Disorder. Coverage for the diagnosis and treatment of Autism Spectrum Disorder is limited to $36,000 annnally and may not excced $200,000 in total benefits. 10.03 Home Health Care Services (SI<iUed Home Health Care). Services are limited to a period of2 hours or less per visit, and 60 visits per calendar year. 10.04 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines, subject to applicable Co-payments as listed for physical, speech and occupational therapies. 31 A V-CHOlCE-2009 MP-5320 (10/09)