Common use of Mastectomy and Breast Reconstruction Services Clause in Contracts

Mastectomy and Breast Reconstruction Services. Benefits are provided for mastectomy necessary due to disease, illness or injury. This benefit covers:  Reconstruction of the breast on which mastectomy has been performed  Surgery and reconstruction of the other breast to produce a symmetrical appearance  Prostheses (including bras)  Physical complications of all stages of mastectomy, including lymphedemas Medical Foods This plan covers medically necessary medical foods for supplementation or dietary replacement for the treatment of inborn errors of metabolism. An example is phenylketonuria (PKU). Benefits include medically necessary enteral formula prescribed by a physician or other health care provider for treatment of eosinophilic gastrointestinal associated disorder or other severe malabsorption disorder. Benefits are provided for all delivery methods of formula. Medical foods are foods that are formulated to be consumed or administered enterally under strict medical supervision. Medical foods generally provide most of a person’s nutrition. Medical foods are designed to treat a specific problem that can be diagnosed using medical tests. This benefit does not cover: Other oral nutrition or supplements not used to treat inborn errors of metabolism, even if prescribed by a physician. Includes but is not limited to specialized infant formulas and lactose-free foods.

Mastectomy and Breast Reconstruction Services. Benefits are provided for mastectomy necessary due to disease, illness or injury. This benefit covers:  • Reconstruction of the breast on which mastectomy has been performed  • Surgery and reconstruction of the other breast to produce a symmetrical appearance  • Prostheses (including bras)  • Physical complications of all stages of mastectomy, including lymphedemas Medical Foods This plan covers medically necessary medical foods for supplementation or dietary replacement for the treatment of inborn errors of metabolism. An example is phenylketonuria (PKU). Benefits include medically necessary enteral formula prescribed by a physician or other health care provider for treatment of eosinophilic gastrointestinal associated disorder or other severe malabsorption disorder. Benefits are provided for all delivery methods of formula. Medical foods are foods that are formulated to be consumed or administered enterally under strict medical supervision. Medical foods generally provide most of a person’s nutrition. Medical foods are designed to treat a specific problem that can be diagnosed using medical tests. This benefit does not cover: Other oral nutrition or supplements not used to treat inborn errors of metabolism, even if prescribed by a physician. Includes but is not limited to specialized infant formulas and lactose-free foods.