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)
<br />
<br />12.09.02 Reconstructive jaw surgery for the treatment of deformities that are present and apparent at
<br />birth; or
<br />
<br />12.09.03 Full mouth extraction when required before radiation therapy.
<br />
<br />12.10 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
<br />behavioral problems and developmental delays. Expenses for remedial or special education, counseling,
<br />or therapy including evaluation and treatment of the above-listed conditions or behavioral training
<br />whether or not associated with manifest mental disorders or other disturbances.
<br />
<br />12.11 Durable Medical Equipment (DME). Non-covered include (but are not limited to) the following:
<br />
<br />12.11.01 Bed Related Items: bed trays, over the bed tables, hed wedges, pillows, custom bedroom
<br />equipment, mattresses, including non-power mattresses, custom mattresses and posturepedic
<br />mattresses;
<br />
<br />')
<br />
<br />12.1 J .02 Bath Related Items: bath lifts, non-portable whirlpools, bathtub rails, toilet rails, raised toilet
<br />seats, bath benches, bath stools, hand held showers, paraffm baths, bath mats, and spas;
<br />
<br />12.11.03 Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about
<br />chairs, geriatric chairs, hip chairs, seat lifts (rnechanical or motorized), patient lifts
<br />(mechanical or motorized - manual hydraulic lifts are covered if patient is 2-person transfer),
<br />and auto tilt chairs;
<br />
<br />12.11.04 Fixtures to Real Property: ceiling lifts and wheelchair ramps;
<br />
<br />12.11.05 CarNan Modifications;
<br />
<br />12.11.06 Air Quality Items: roorn humidifiers, vaporizers, air purifiers and electrostatic machines;
<br />
<br />12.11.07 Blood/Injection Related Items: blood pressure cuffs, centrifuges, nova pens and needle less
<br />injectors; and
<br />
<br />12.11.08 Other Equiprnent: heat lamps, heating pads, cryounits, cryotherapy machines, electronic-
<br />controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
<br />hoard, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair
<br />gliders, elevators, saunas, any exercise equipment and diathermy machines.
<br />
<br />12.12 Emergency room services for non-emergency purposes. See Sections 3.16 and 3.17.
<br />
<br />12.13 Exercise programs, gyrn memberships, or exercise equiprnent of any kind, including, but not limited
<br />to: exercise bicycles, treadmills, stairmasters, rowing machines, free weights or resistance equipment.
<br />Also excluded are massage devices, portable whirlpool pumps, hot tubs, jacuzzis, sauna baths,
<br />swimming pools and similar equipment.
<br />
<br />12.14 Experimental and/or investigational procedures, except for bone marrow transplants, as approved per
<br />Florida Administrative Code, Section 59B-12.001. For the purposes of this Contract, a medication,
<br />treatment, device, surgery or procedure may be determined to be experimental and/or investigational if
<br />any of the following applies:
<br />
<br />12.14.01 The FDA has not granted the approval for general use;
<br />
<br />12.14.02 There are insufficient outcomes data available frorn controlled clinical trials published in
<br />peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury
<br />involved;
<br />
<br />12.14.03 There is no consensus among practicing physicians that the medication, treatment, therapy,rprocedure or device is safe or effective for the treatment in question or such medication,
<br />treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or
<br />
<br />.j
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<br />A V-0100-2009
<br />MP-5319 (10/09)
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