Services Not Medically Necessary Sample Clauses
Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, behavioral health services, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary. We will use any reasonable means to make a determination about the medical necessity of this care. We may look at medical records, reports and utilization review committee statements. We review medical necessity in accordance with our medical policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may deny payments if a doctor or hospital does not supply medical records needed to determine medical necessity. We may also deny or reduce payment if the records sent to us do not provide adequate justification for performing the service. This agreement does NOT cover routine screenings or tests performed by a hospital which are not medically necessary for the diagnosis or treatment of your condition. This agreement does NOT cover routine screenings or tests which are not specifically ordered by the doctor who admits you.
Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines. Services Not Performed Within Indicated Time Limitations - Dental services performed that do not comply with the timeframes and limitations as set forth in this agreement and in our dental policies and related guidelines are NOT covered. Anesthesia - General anesthesia and intravenous sedation are NOT covered unless rendered in conjunction with covered oral surgical procedures. Covered dental care services excludes the services of an anesthesiologist. Cosmetic Services - This agreement does NOT cover cosmetic procedures. Cosmetic procedures are performed to refine or reshape dental structures that are not functionally impaired, to change or improve appearance or improve self-esteem, or for other psychological, psychiatric or emotional reasons. Implants - This agreement does NOT cover dental implants, implant support prosthesis, or other implant related services, except for a single tooth implants which are covered as a prosthodontic service if placed as an alternative treatment to a conventional 3-unit bridge, replacing only one missing tooth with sound natural teeth on either side. Experimental/investigational Services - This agreement does NOT cover experimental or investigational procedures or services. Experimental or investigational procedures or services are not included in our dental policies and related guidelines. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective. Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen. New Dental Services - This agreement does NOT cover any new dental procedures or services that are not included in our dental policies and related guidelines. Services Performed By Hospital Staff Employees - This agreement does NOT cover pediatric dental services rendered at a hospital by interns, residents, or staff dentists. Specialty Oral Examinations - We will NOT cover oral examinations (limited in scope) when performed by a dentist who limits his or her practice to a specialty branch of dentistry. This includes, but is not limited to, oral examinations relating to periodontics, orthodontics, endodontics, oral surgery, and prosthodontics. Temporomandibular Joint Syndr...
Services Not Medically Necessary. Payment will be denied for services provided by Group that BlueLincs HMO determines to be not Medically Necessary or Experimental/Investigational/Unproven. Such denied charges may not be collected from the BlueLincs HMO Member.
Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which we determine is NOT medically necessary. (See Section 7.0 - Glossary). We have the right and discretionary authority to use any reasonable means to determine the medical necessity of this care and we may examine hospital records, reports and hospital utilization review committee statements. We have the right to deny payments if a doctor or hospital does not supply medical records required to determine medical necessity. We also have the right to deny or reduce payment if the records supplied do not provide adequate justification for performing the service. If the hospital performs routine screenings or tests which are not medically necessary for the diagnosis or treatment of your condition or which are not specifically ordered by the doctor who admits you, this agreement does NOT cover them.
Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines. • Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen. See Section 4.18 for other Dental Services not covered under this agreement.
Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary.