Common use of Air and Water Ambulance Services Clause in Contracts

Air and Water Ambulance Services. Air or water ambulance transportation services, when the destination is not to an acute care hospital. Some examples of non-covered air or water ambulance services include transport to a physician’s office, nursing facility, or a patient’s home. • Transport services from a cruise ship when not in United States waters. Behavioral Health Services • Therapeutic recreation programs or wilderness programs. • Recreation therapy, non-medical self-care, or self-help training (e.g. Alcoholics Anonymous (AA), Narcotics Anonymous (NA) meetings/services). • Services provided in any covered program that are recreational therapy programs, wilderness programs, educational programs, complimentary programs, or non- clinical services. Examples include, but are not limited to, Tai Chi, yoga, personal training, meditation. • Computer /internet/social media based services and/or programs. • Behavioral training assessment, education, or exercise services unless provided for applied behavioral analysis. • Psychoanalysis for educational purposes, regardless of symptoms. • Psychotherapy services you may receive which are credited towards a degree or to further your education or training. Chiropractic Services • Chiropractic services received in your home. Dental Services The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. Dialysis Services • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the machine. • Dialysis services received in a physician’s office. Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) • Items typically found in the home that do not need a prescription and are easily obtainable such as, but not limited to: o adhesive bandages; o elastic bandages; o gauze pads; and o alcohol swabs. • DME and medical supplies prescribed primarily for the convenience of the member or the member’s family, including but not limited to, duplicate DME or medical supplies for use in multiple locations or any DME or medical supplies used primarily to assist a caregiver. • Non-wearable automatic external defibrillators. • Replacement of durable medical equipment and prosthetic devices prescribed because of a desire for new equipment or new technology. • Equipment that does not meet the basic functional need of the average person. • DME that does not directly improve the function of the member. • Medical supplies provided during an office visit. • Pillows or batteries, except when used for the operation of a covered prosthetic device, or items for which the sole function is to improve the quality of life or mental wellbeing. • Repair or replacement of DME when the equipment is under warranty, covered by the manufacturer, or during the rental period. • Infant formula, nutritional supplements and food, or food products, whether or not prescribed, unless required by R.I. Law §27-20-56 for Enteral Nutrition Products, or delivered through a feeding tube as the sole source of nutrition. • Corrective or orthopedic shoes and orthotic devices used in connection with footwear, unless for the treatment of diabetes. Experimental or Investigational Services • Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigational except as described in Section 3. Gender Reassignment Services • Reversal of gender reassignment surgery.

Air and Water Ambulance Services.  Air or water ambulance transportation services, when the destination is not to an acute care hospital. Some examples of non-covered air or water ambulance services include transport to a physician’s office, nursing facility, or a patient’s home. •  Transport services from a cruise ship when not in United States waters. Behavioral Health Services •  Therapeutic recreation programs or wilderness programs. •  Recreation therapy, non-medical self-care, or self-help training (e.g. Alcoholics Anonymous (AA), Narcotics Anonymous (NA) meetings/services). •  Services provided in any covered program that are recreational therapy programs, wilderness programs, educational programs, complimentary programs, or non- clinical services. Examples include, but are not limited to, Tai Chi, yoga, personal training, meditation. •  Computer /internet/social media based services and/or programs. •  Behavioral training assessment, education, or exercise services unless provided for applied behavioral analysis. •  Psychoanalysis for educational purposes, regardless of symptoms. •  Psychotherapy services you may receive which are credited towards a degree or to further your education or training. Chiropractic Services • services  Chiropractic services received in your home. Dental Services services The following dental services are not covered, except as described under Dental Services in Section 3: •  Dental injuries incurred as a result of biting or chewing. •  General dental services such as extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. •  Panorex x-rays or dental x-rays. •  Orthodontic services, even if related to a covered surgery. •  Dental appliances or devices. •  Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. Dialysis Services •  The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training you or members of your family in the operation of the machine. •  Dialysis services received in a physician’s office. Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) • Items typically found in the home that do not need a prescription and are easily obtainable such as, but not limited to: o adhesive bandages; o elastic bandages; o gauze pads; and o alcohol swabs. • DME and medical supplies prescribed primarily for the convenience of the member or the member’s family, including but not limited to, duplicate DME or medical supplies for use in multiple locations or any DME or medical supplies used primarily to assist a caregiver. • Non-wearable automatic external defibrillators. • Replacement of durable medical equipment and prosthetic devices prescribed because of a desire for new equipment or new technology. • Equipment that does not meet the basic functional need of the average person. • DME that does not directly improve the function of the member. • Medical supplies provided during an office visit. • Pillows or batteries, except when used for the operation of a covered prosthetic device, or items for which the sole function is to improve the quality of life or mental wellbeing. • Repair or replacement of DME when the equipment is under warranty, covered by the manufacturer, or during the rental period. • Infant formula, nutritional supplements and food, or food products, whether or not prescribed, unless required by R.I. Law §27-20-56 for Enteral Nutrition Products, or delivered through a feeding tube as the sole source of nutrition. • Corrective or orthopedic shoes and orthotic devices used in connection with footwear, unless for the treatment of diabetes. Experimental or Investigational Services • Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigational except as described in Section 3. Gender Reassignment Services • Reversal of gender reassignment surgery.