Common use of Prosthetics Clause in Contracts

Prosthetics. This benefit covers prosthetic devices for functional reasons to replace a missing body part, including artificial limbs, external breast prostheses following a mastectomy, and maxillofacial prostheses. Prosthetic devices or appliances that are surgically inserted into the body are covered under the appropriate Hospital Care benefit. Rehabilitation Services Coverage for disabling conditions is provided through inpatient and outpatient rehabilitation therapy services. Examples of such services include: physical therapy, speech therapy, and occupational therapy. The following conditions must be met: • Services are to restore and significantly improve function that was previously present but lost due to acute Injury or Illness; • Services are not for palliative, recreational, relaxation or maintenance therapy; and • Loss of function was not the result of a work-related Injury. Coverage for cardiac rehabilitation requires that Members have experienced a cardiac event in the preceding 12 month period, such as myocardial infarction, chronic stable angina, heart transplant or heart and lung transplants. Inpatient Rehabilitation Inpatient rehabilitation services require Pre-Authorization and must be furnished and billed by a rehabilitative unit of a Hospital or by another approved rehabilitation facility. When rehabilitation follows acute care in a continuous inpatient stay, this benefit starts on the day the care becomes primarily rehabilitative. Inpatient care includes room and board, services provided and billed by the inpatient facility, and therapies performed during the rehabilitative stay. Outpatient Rehabilitation Outpatient rehabilitation benefits are subject to the following provisions: • You must not be confined in a Hospital or other Medical Facility; and • Services must be billed by a Hospital, physician, or physical, occupational, speech or massage therapist. Speech therapy is covered only when required as a result of brain or nerve damage secondary to an accident, disease or stroke. Once the benefits under this provision are exhausted for a particular condition, coverage may not be extended by using the benefits under any other provision. NOTE: Outpatient rehabilitation therapy services are subject to a combined total maximum of 25 visits per Member per Calendar Year. Skilled Nursing Facility Services Inpatient Skilled Nursing Facility care requires Pre-Authorization. Benefits include inpatient services and supplies of a Skilled Nursing Facility for treatment of an Illness, Injury or physical disability, as well as Pharmacy services and Prescriptions filled in the Skilled Nursing Facility. Skilled Nursing Facility services are covered when provided as an alternative to hospitalization and prescribed by your Provider. Room and board is limited to a semi-private room, except when a private room is determined to be Medically Necessary. Care must be therapeutic or restorative and require in-facility delivery by licensed professional medical personnel, under the direction of a physician, to obtain the desired medical outcome, including services provided by a licensed behavioral health Provider for a covered diagnosis. Maintenance and Custodial Care are not covered. Spinal Manipulations Spinal manipulations by a qualified Provider are covered, and are subject to the maximum benefit limit listed in the Schedule of Medical Benefits above. Coverage includes manipulation of the spine, diagnostic radiology, and diagnosis and treatment of musculoskeletal disorders, when performed within the scope of the Provider’s license. Temporomandibular Joint (“TMJ”) Disorders Pre-Authorization is required for inpatient admissions related to TMJ. Inpatient and outpatient services are covered for the treatment of TMJ when Medically Necessary. Dental services and dentist charges related to the treatment of TMJ are not covered by this plan.

Prosthetics. This benefit covers prosthetic devices for functional reasons to replace a missing body part, including artificial limbs, external breast prostheses following a mastectomy, mastectomy and maxillofacial prostheses. Prosthetic devices or appliances that are surgically inserted into the body are covered under the appropriate Hospital Care benefitfacility provision in this section. Rehabilitation Services Coverage for disabling conditions is provided through inpatient and outpatient rehabilitation therapy servicestherapy. Examples of such services therapies include: , but are not limited to, physical therapy, speech therapy, and occupational therapy. The following conditions must be met: •  Services are to restore and significantly improve function that was previously present but lost due to acute Injury or Illness; • ,  Services are not for palliative, recreational, relaxation or maintenance therapy; , and •  Loss of function was not the result of a work-related work‐related Injury. Coverage for cardiac rehabilitation requires that Members have experienced a cardiac event in the preceding 12 month period, such as myocardial infarction, chronic stable angina, heart transplant transplants or heart and lung transplants. Inpatient Rehabilitation Inpatient rehabilitation services require Pre-Authorization requires pre‐authorization and must be furnished and billed by a rehabilitative unit of a Hospital or by another approved rehabilitation facility. When rehabilitation follows acute care in a continuous inpatient stay, this benefit starts on the day the care becomes primarily rehabilitative. Inpatient care includes all room and board, services provided and billed by the inpatient facility, facility and therapies performed during the rehabilitative stay. Outpatient Rehabilitation Outpatient rehabilitation benefits are subject to the following provisions: •  You must not be confined in a Hospital or other Medical Facility; and •  Services must be furnished and billed by a Hospital, physician, or physical, occupational, speech or massage therapist. Speech therapy is covered only when required as a result of brain or nerve damage secondary to an accident, disease or stroke. Once the benefits under this provision are exhausted for a particular conditionexhausted, coverage may not be extended by using the benefits under any other provision. NOTE: Outpatient rehabilitation therapy services are subject to a combined total maximum of 25 visits per Member member per Calendar Year. Skilled Nursing Facility Services Inpatient Skilled Nursing Facility care requires Pre-Authorizationpre‐authorization. Benefits include inpatient services and supplies of a Skilled Nursing Facility for treatment of an Illness, Injury or physical disability, disability as well as Pharmacy services and Prescriptions filled in the Skilled Nursing Facility. Skilled Nursing Facility services are covered when provided as an alternative to hospitalization and prescribed by your Provider. Room and board is limited to a semi-private semi‐private room, except when a private room is determined to be Medically Necessarynecessary. Care must be therapeutic or restorative and require in-in‐ facility delivery by licensed professional medical personnel, under the direction of a physician, to obtain the desired medical outcome, including services provided by a licensed behavioral health Provider for a covered diagnosis. Maintenance and Custodial Care are not covered. Spinal Manipulations Spinal manipulations by a qualified Provider are covered, and are subject to the maximum benefit limit listed in the Schedule of Medical Benefits above. Coverage includes manipulation of the spine, diagnostic radiology, and diagnosis and treatment of musculoskeletal disorders, when performed within the scope of the Provider’s license. Temporomandibular Joint (“TMJ”) Disorders Pre-Authorization is required for inpatient admissions related to TMJ. Inpatient and outpatient services are covered for the treatment of TMJ when Medically Necessary. Dental services and dentist charges related to the treatment of TMJ are not covered by this planfor maintenance or Custodial Care.