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<br />
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<br />
<br />device utilized by practicing physicians in treating other patients with the same or a similar
<br />condition; or
<br />
<br />Such rnedication, treatment, procedure or device is the subject of an ongoing Phase I or
<br />Phase 11 clinical investigation, or experimental or research arm of a Phase ill clinical
<br />investigation, or under study to determine: maximum tolerated dosages, toxicity, safety,
<br />efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the
<br />condition in question:
<br />
<br />12.15 Eye care including:
<br />
<br />12.15.01 Eye examinations for Members 18 years of age or older for the purpose of determining the
<br />need for sight correction (such as eye glasses or contact lenses);
<br />
<br />12.14.04
<br />
<br />lil
<br />
<br />Training or orthoptics, including eye exercises; or
<br />
<br />Radial keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
<br />procedure to correct refractive error.
<br />
<br />12.16 Foot supports are not covered. These include orthopedic or specialty shoes, shoe build-ups, shoe
<br />orthotics, shoe braces, and shoe supports. Also excluded is routine foot care, including trimming of
<br />corns, calluses, and nails.
<br />
<br />12.15.02
<br />12.15.03
<br />
<br />12.17 Gastric stapling, gastric bypass, gastric banding, gastric bubbles, and other procedures for the
<br />treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests. Ongoing
<br />visits other than establishing a program of obesity control.
<br />
<br />12.18 Gender reassignment surgery as well as any service, supply, or medical care associated with gender
<br />reassignment or gender identity disorders.
<br />
<br />12.19 Home monitoring devices and measuring devices (other than apnea monitors), and any other
<br />equipment or devices for use outside the Hospital.
<br />
<br />12.20 Hospital Services that are associated with excluded surgery or Dental Care.
<br />
<br />12.21 Hearing examinations for Members 18 years of age or older for the purpose of determining the need
<br />for hearing correction.
<br />
<br />12.22 Infertility diagnosis, trcatment, and supplics, including infertility testing, treatment of infertility,
<br />diagnostic procedures and artificial insemination, to determine or correct the cause or reason for
<br />infertility or inability to achieve conception. This includes artificial insemination, in-vitro fertilization,
<br />ovwn or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other
<br />preservation techniques used in such or sirnilar procedures. Also excluded are obstetrical benefits when
<br />such pregnancy is the subject of a preplanned adoption arrangement, or surrogacy, as defined under
<br />Cbapter 63, Florida Statutes. Medications for the treatment of infertility are not covered.
<br />
<br />12.23 Immunizations and medications for the purpose of foreign travel or employment.
<br />
<br />12.24 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused
<br />by congenital or developmental deformity, disease, or injury.
<br />
<br />12.25 Medical care or surgery not authorized by a Participating provider, except for Ernergency Medical
<br />Services and Care, or not within the benefits covered by AvMed.
<br />
<br />12.26 Medical supplies including, but not limited to: pre-fabricated splints, Thromboemboletic/Support hose
<br />and all other bandages, except as provided in Sections 10.22 and 10.37.
<br />
<br />12.27 Non-participating Providers. Any treatment or service frorn a Non-participating Provider, except in
<br />the case of an ernergency or when specifically pre-authorized by AvMed (see Sections 3.16 and 3.17),
<br />
<br />32
<br />
<br />A V-GlOO.2009
<br />MP-5319 (10/09)
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