Common use of Non-emergency ambulance services Clause in Contracts

Non-emergency ambulance services. Medically Nec- xxxxxx ambulance Services to transfer the Member from a non-Plan Hospital to a Plan Hospital or between Plan facilities when in connection with authorized confine- ment/admission and use of the ambulance is authorized. AMBULATORY SURGERY CENTER BENEFITS Benefits are provided for Ambulatory Surgery Center Bene- fits on an Outpatient facility basis at an Ambulatory Surgery Center. Note: Outpatient ambulatory surgery Services may also be obtained from a Hospital or an Ambulatory Surgery Center that is affiliated with a Hospital, and will be paid according to Hospital Benefits (Facility Services) in the Plan Benefits sec- tion. Benefits are provided for Medically Necessary Services in connection with Reconstructive Surgery when there is no other more appropriate covered surgical procedure, and with regards to appearance, when Reconstructive Surgery offers more than a minimal improvement in appearance. In accord- ance with the Women’s Health and Cancer Rights Act, surgi- cally implanted and other prosthetic devices (including pros- thetic bras) and Reconstructive Surgery is covered on either breast to restore and achieve symmetry incident to a mastec- tomy, and treatment of physical complications of a mastec- tomy, including lymphedemas. Surgery must be authorized as described herein. Benefits will be provided in accordance with guidelines established by the Plan and developed in con- junction with plastic and reconstructive surgeons. No benefits will be provided for the following surgeries or procedures unless for Reconstructive Surgery: 1. Surgery to excise, enlarge, reduce, or change the appear- ance of any part of the body; 2. Surgery to reform or reshape skin or bone; 3. Surgery to excise or reduce skin or connective tissue that is loose, wrinkled, sagging, or excessive on any part of the body; 4. Hair transplantation; and 5. Upper eyelid blepharoplasty without documented signif- icant visual impairment or symptomatology. This limitation shall not apply to breast reconstruction when performed subsequent to a mastectomy, including surgery on either breast to achieve or restore symmetry. CLINICAL TRIAL FOR CANCER BENEFITS Benefits are provided for routine patient care for a Member whose Personal Physician has obtained prior authorization and who has been accepted into an approved clinical trial for cancer provided that: 1. the clinical trial has a therapeutic intent and the Mem- ber’s treating Physician determines that participation in the clinical trial has a meaningful potential to benefit the Member with a therapeutic intent; and 2. the Member’s treating Physician recommends participa- tion in the clinical trial; and

Non-emergency ambulance services. Medically Nec- xxxxxx Neces- sary ambulance Services to transfer the Member from a non-Plan Hospital to a Plan Hospital or between Plan facilities fa- cilities when in connection with authorized confine- ment/admission and use of the ambulance is authorized. AMBULATORY SURGERY CENTER BENEFITS Benefits are provided for Ambulatory Surgery Center Bene- fits Benefits on an Outpatient facility basis at an Ambulatory Surgery CenterCen- ter. Note: Outpatient ambulatory surgery Services may also be obtained from a Hospital or an Ambulatory Surgery Center that is affiliated with a Hospital, and will be paid according to Hospital Benefits (Facility Services) in the Plan Benefits sec- tion. Benefits are provided for Medically Necessary Services in connection with Reconstructive Surgery when there is no other oth- er more appropriate covered surgical procedure, and with regards to appearance, when Reconstructive Surgery offers more than a minimal improvement in appearance. In accord- ance with the Women’s Health and Cancer Rights Act, surgi- cally implanted and other prosthetic devices (including pros- thetic bras) and Reconstructive Surgery is covered on either breast to restore and achieve symmetry incident to a mastec- tomy, and treatment of physical complications of a mastec- tomymastecto- my, including lymphedemas. Surgery must be authorized as described herein. Benefits will be provided in accordance with guidelines established by the Plan and developed in con- junction with plastic and reconstructive surgeons. No benefits will be provided for the following surgeries or procedures unless for Reconstructive Surgery: 1. Surgery to excise, enlarge, reduce, or change the appear- ance of any part of the body; 2. Surgery to reform or reshape skin or bone; 3. Surgery to excise or reduce skin or connective tissue that is loose, wrinkled, sagging, or excessive on any part of the body; 4. Hair transplantation; and 5. Upper eyelid blepharoplasty without documented signif- icant signifi- cant visual impairment or symptomatology. This limitation shall not apply to breast reconstruction when performed subsequent to a mastectomy, including surgery on either breast to achieve or restore symmetry. CLINICAL TRIAL FOR CANCER BENEFITS Benefits are provided for routine patient care for a Member whose Personal Physician has obtained prior authorization and who has been accepted into an approved clinical trial for cancer can- cer provided that: 1. the clinical trial has a therapeutic intent and the Mem- ber’s treating Physician determines that participation in the clinical trial has a meaningful potential to benefit the Member with a therapeutic intent; and 2. the Member’s treating Physician recommends participa- tion in the clinical trial; and