Common use of Reconstructive Surgery Benefits Clause in Contracts

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance to the extent possible. Benefits include dental and orthodontic services that are an integral part of this surgery for cleft palate procedures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, Occupational, and Respiratory Therapy pursuant to a written treatment plan, and when rendered in the provider’s office or outpatient department of a Hospital. Blue Shield reserves the right to periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage for Rehabilitation/Habilitation services rendered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- standing Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered by a Physician or other appropriately licensed or certified Health Care Provider pursuant to a written treatment plan to: correct or improve (1) a communication impairment; (2) a swallowing disorder; (3) an expressive or receptive language disorder; or (4) an abnormal delay in speech development. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, and likely to result in clinically significant progress as measured by objective and standardized tests. The provider’s treatment plan and records may be reviewed periodically for Medical Necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefits.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defectsde- fects, developmental abnormalities, trauma, infectioninfec- tion, tumors, or disease to do either of the followingfollow- ing: (1) to improve function, or (2) to create a normal nor- mal appearance to the extent possible. Benefits include in- clude dental and orthodontic services that are an integral part of this surgery for cleft palate proceduresproce- dures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident inci- dent to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemaslym- phedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed devel- oped in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, OccupationalOc- cupational, and Respiratory Therapy for the treat- ment of functional disability in the performance of activities of daily living. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary pursuant to a written the treatment plan, to help the Member regain his or her previ- ous level of functioning or to keep, learn, or im- prove skills and when rendered in the provider’s office or outpatient department of a Hospitalfunctioning. Blue Shield reserves the right to may periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the Speech Therapy Benefits (Rehabilitation and Habil- itative Services) section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage cov- erage for Rehabilitation/Habilitation Habilitative services rendered ren- dered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- standing Skilled Nursing Facility, up to the Benefit Bene- fit maximum as shown on the Summary of BenefitsBene- fits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-semi- private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Ben- efit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered by a Physician or other appropriately licensed or certified Health Care Provider pursuant to a written Ther- apy for the treatment plan to: correct or improve of (1) a communication impairmentim- pairment; (2) a swallowing disorder; (3) an expressive expres- sive or receptive language disorder; or (4) an abnormal ab- normal delay in speech development. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, Necessary pursuant to the treatment plan, to help the Member regain his or her previous performance level or to keep, learn, or improve skills and likely to result in clinically significant progress as measured by objective and standardized testsfunctioning. The Blue Shield may periodically review the provider’s treatment plan and records may be reviewed periodically for Medical Necessity. Except as specified above and as stated under Note: See the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided sections for informa- tion on coverage for Speech Therapy, speech correction, or speech pathology servicesTherapy Services ren- dered in the home. See the Hospital Benefits (Facility Fa- cility Services) section for information on inpatient Benefits.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance to the extent possible. Benefits include dental and orthodontic services that are an integral part of this surgery for cleft palate procedures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, Occupational, and Respiratory Therapy pursuant to a written treatment plan, and when rendered in the provider’s office or outpatient department of a Hospital. Blue Shield reserves the right to periodically review the provider’s treatment plan and records for Medical Necessity. .. Benefits for Speech Therapy are described in the Speech Therapy Benefits section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage for Rehabilitation/Habilitation services rendered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- free-standing Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are provided for Medically Necessary outpatient Speech Therapy services when ordered by a Physician or other appropriately licensed or certified Health Care Provider pursuant covered on either breast to restore and achieve symmetry incident to a written mastectomy, and treatment plan to: correct or improve (1) of physical complications of a communication impairment; (2) a swallowing disorder; (3) an expressive or receptive language disorder; or (4) an abnormal delay in speech developmentmastectomy, including lymphedemas. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, in accordance with guidelines established by Blue Shield and likely to result developed in clinically significant progress as measured by objective conjunction with plastic and standardized tests. The provider’s treatment plan and records may be reviewed periodically for Medical Necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefitsreconstructive surgeons.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance to the extent possible. Benefits include dental and orthodontic services that are an integral part of this surgery for cleft palate procedures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, Occupational, and Respiratory Therapy pursuant to a written treatment plan, and when rendered in the provider’s office or outpatient department of a Hospital. Blue Shield reserves the right to periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the Speech Therapy Benefits section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage for Rehabilitation/Habilitation services rendered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- free-standing Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered and provided by a Physician by an appropriately licensed speech therapist or other appropriately licensed or certified Health Care Provider Provider, pursuant to a written treatment plan for an appropriate time to: (1) correct or improve (1) a communication impairmentthe speech abnormality; (2) a swallowing disorderevaluate the effectiveness of treatment; or (3) an expressive provide Habilitation services for the Member. Services are covered when rendered in the provider’s office or receptive language disorder; outpatient department of a Hospital. Services are provided for the correction of, or (4) an abnormal delay in clinically significant improvement of, speech developmentabnormalities that are the likely result of a diagnosed and identifiable medical condition, illness, or injury to the nervous system or to the vocal, swallowing, or auditory organs, and to Members diagnosed with Severe Mental Illness or Serious Emotional Disturbances of a Child. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, and likely to result in clinically significant progress as measured by objective and standardized tests. The provider’s treatment plan and records may will be reviewed periodically for Medical Necessitymedical necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefits.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance to the extent possible. Benefits include dental and orthodontic services that are an integral part of this surgery for cleft palate procedures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, Occupational, and Respiratory Therapy pursuant to a written treatment plan, and when rendered in the provider’s office or outpatient department of a Hospital. Blue Shield reserves the right to periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the Speech Therapy Benefits section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage for Rehabilitation/Habilitation services rendered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- free-standing Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered and provided by a Physician by an appropriately licensed speech therapist, or other appropriately licensed or certified Health Care Provider pursuant to a written treatment plan for an appropriate time to: (1) correct or improve (1) a communication impairmentthe speech abnormality; (2) a swallowing disorderevaluate the effectiveness of treatment; or (3) an expressive provide Habilitation services for the Member. Services are covered when rendered in the provider’s office or receptive language disorder; outpatient department of a Hospital. Services are provided for the correction of, or (4) an abnormal delay in clinically significant improvement of, speech developmentabnormalities that are the likely result of a diagnosed and identifiable medical condition, illness, or injury to the nervous system or to the vocal, swallowing, or auditory organs, and to Members diagnosed with Severe Mental Illness or Serious Emotional Disturbances of a Child. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, and likely to result in clinically significant progress as measured by objective and standardized tests. The provider’s treatment plan and records may will be reviewed periodically for Medical Necessitymedical necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefits.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance to the extent possible. Benefits include dental and orthodontic services that are an integral part of this surgery for cleft palate procedures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, Occupational, and Respiratory Therapy pursuant to a written treatment plan, and when rendered in the provider’s office or outpatient department of a Hospital. Blue Shield reserves the right to periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the Speech Therapy Benefits section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage for Rehabilitation/Habilitation services rendered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- free-standing Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered and provided by a Physician by an appropriately licensed speech therapist, or other appropriately licensed or certified Health Care Provider pursuant to a written treatment plan for an appropriate time to: (1) correct or improve (1) a communication impairmentthe speech abnormality; (2) a swallowing disorderevaluate the effectiveness of treatment; or (3) an expressive provide Habilitation services for the Member. Services are covered when rendered in the provider’s office or receptive language disorder; outpatient department of a Hospital. Services are provided for the correction of, or (4) an abnormal delay in clinically significant improvement of, speech developmentabnormalities that are the likely result of a diagnosed and identifiable medical condition, illness, or injury to the nervous system or to the vocal, swallowing, or auditory organs, and to Members diagnosed with Severe Mental Illness or Serious Emotional Disturbances of a Child. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, and likely to result in clinically significant progress as measured by objective and standardized tests. The provider’s treatment plan and records may will be reviewed periodically for Medical Necessitymedical necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefits.

Reconstructive Surgery Benefits. Benefits are provided to correct or repair abnormal structures of the body caused by congenital defectsde- fects, developmental abnormalities, trauma, infectioninfec- tion, tumors, or disease to do either of the followingfollow- ing: (1) to improve function, or (2) to create a normal nor- mal appearance to the extent possible. Benefits include in- clude dental and orthodontic services that are an integral part of this surgery for cleft palate proceduresproce- dures. Reconstructive Surgery is covered to create a normal appearance only when it offers more than a minimal improvement in appearance. In accordance with the Women’s Health & Cancer Rights Act, Reconstructive Surgery, and surgically implanted and non-surgically implanted prosthetic devices (including prosthetic bras), are covered on either breast to restore and achieve symmetry incident inci- dent to a mastectomy, and treatment of physical complications of a mastectomy, including lymphedemaslym- phedemas. Benefits will be provided in accordance with guidelines established by Blue Shield and developed devel- oped in conjunction with plastic and reconstructive surgeons. Benefits are provided for outpatient Physical, OccupationalOc- cupational, and Respiratory Therapy for the treat- ment of functional disability in the performance of activities of daily living. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary pursuant to a written the treatment plan, to help the Member regain his or her previ- ous level of functioning or to keep, learn, or im- prove skills and when rendered in the provider’s office or outpatient department of a Hospitalfunctioning. Blue Shield reserves the right to may periodically review the provider’s treatment plan and records for Medical Necessity. Benefits for Speech Therapy are described in the Speech Therapy Benefits (Rehabilitative and Habil- itative Services) section. See the Home Health Care Benefits and Hospice Program Benefits sections for information on coverage cov- erage for RehabilitationRehabilitative/Habilitation Habilitative services rendered ren- dered in the home. Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a free- standing Skilled Nursing Facility, up to the Benefit Bene- fit maximum as shown on the Summary of Benefits. The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded. A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received. A new Benefit Period can begin only after an existing Benefit Period ends. Benefits are provided for Medically Necessary outpatient Speech Therapy services when ordered by a Physician or other appropriately licensed or certified Health Care Provider pursuant to a written treatment plan to: correct or improve (1) a communication impairment; (2) a swallowing disorder; (3) an expressive or receptive language disorder; or (4) an abnormal delay in speech development. Continued outpatient Benefits will be provided as long as treatment is Medically Necessary, pursuant to the treatment plan, and likely to result in clinically significant progress as measured by objective and standardized tests. The provider’s treatment plan and records may be reviewed periodically for Medical Necessity. Except as specified above and as stated under the Home Health Care Benefits and Hospice Program Benefits sections, no outpatient benefits are provided for Speech Therapy, speech correction, or speech pathology services. See the Hospital Benefits (Facility Services) section for information on inpatient Benefits.Bene-