Reso 2010-1529 - Laserfiche WebLink

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') ) n 10.05 Licenced dietitions/nutritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes, renal disease or obesity control shall be limited to 3 outpatient visits per calendar year and each visit requires a Co-payment. See Schedule of Benefits and Section 11.17. 10.06 Major Organ Transplants - transportation services. 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 transplant contracted facilities. 10.07 Orthotic appliances. Coverage for orthotic appliances is limited to custom-made leg, arm, back and neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when necessary to carry out nonnal activities of daily living, excluding sports activities. 10.08 Other Health Care Facility(ies). All routine inpatient services of other health care facilities (See Section 2.40), including physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered for a maximum of 20 days per calendar year when a Member is admitted to such a facility, following discharge from a Hospital, for a condition that cannot be adequately treated with Home Health Care Services or on an ambulatory basis. 10.09 Physical and occupational therapy. Physical and occupational therapies shall be limited as explained in Section 9.27. 10.10 Prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. 10.11 Second medical opinions. AvMed may limit second medical opinions in connection with a particular diagnosis or treatment to three per calendar year, if AvMed deems additional opinions to be an \ unreasonable over-utilization by the Member. 10.12 Speech therapy. Coverage is limited to 24 visits per calendar year including evaluations. 10.13 Substance abuse--Hospital Limitation. Inpatient services for alcohol and drug abuse shall be provided but only for acute detoxification and the treatment of other medical sequelae of such abuse. Inpatient alcohol or drug rehabilitation services are not covered. 10.14 Supplies. Provision of ostomy, urostomy and wound care supplies are limited to a one-month supply every 30 days. Coverage is limitcd to $2,500 per Contract Year, subject to applicable Co-payments and Co-Insurance. 10.15 Ventilator dependent care. The total benefit for ventilator dependent care is limited to 100 calendar days lifetime maximum. XI. EXCLUSIONS FROM BASIC BENEFITS Medical Services and benefits for the following classifications and conditions are not covered and are excluded from the Schedule of Basic Benefits provided under this Contract: 11.01 Aids or devices that assist with nonverbal communications, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (I'D As) Braille typewriters, visual alcrt systems for the deaf and memory books. 11.02 Armed forces service-connected medical care for both sickness and injury. 32 A V-CIIOlCE-2009 MP-5320 (10/09)