Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

) 10.01.03 Ground transportation to a Member's home will be covered when associated with an approved hospitalization or other confmement and the Member's condition requires the skill of medically trained personnel. Transportation is not covered when the skill of medically trained personnel is not required and the Member can be safely transferred (or transported) hy other means. 10.01.04 Air ambulance transportation is covered only when the point of pick-up is inaccessible by land or when distance or other obstacles are involved in transporting the Member to the nearest emergency department equipped to adequately treat the medical condition. See Part XU for Exclusions. 10.02 Cardiac rehabilitation. Cardiac rehabilitation is covered for the following conditions: acute myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), repair or replacement of heart valves or heart transplant. Coverage is limited to a maximum of 18 visits per calendar year. See Schedule of Benefits for detailed information regarding Co-payments and Limitations. 10.03 Coverage for cleft lip and cleft palate for Members under 18 years of age. The coverage provided hy this Section is subject to the terms and conditions applicable to other benefits. 10.04 Dermatological services. AvMed will cover office visits to a participating dermatologist for Medically Necessary covered services subject to Section 3.30. No prior referral is required for these services. 10.05 Diabetes treatment includes all Medically Necessary equipment, supplies, and services to treat diabetes. This includes outpatient self-management training and educational services, if the Member's Primary Care Physician or the physician to whom the Member has been referred who specializes in diabetes treatment, certifies the equipment, supplies or services are Medically Necessary. Insulin pumps are covered under Suhsection 10.10.05. Diabetes outpatient self-rnanagement training and educational services must be provided under the direct supervision of a certified diabetes educator or a board certified endocrinologist under contract with AvMed. In accordance with Florida Statutes, coverage of insulin purnps for the treatment of diabetes will not apply toward or be subject to the annual DME maximum limitation. See also Section 10.06. 10.06 Diabetic supplies. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing Group's supplemental prescription medication benefits. In the event a Subscribing Group does not purchase supplemental prescription medication benefits, insulin, insulin syringes, lancets, and test strips are covered subject to a $25 Co-payment per item for a 30-day supply. See also 10.05. 10.07 Diagnosis and treatment of Autism Spectrum Disorder through speech therapy, occupational therapy, physical therapy, and Applied Behavior Analysis services for an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developrnental disability at 8 years of age or younger. 10.07.01 Coverage shall be lirnited to services that are prescribed by the treating physician in accordance with a treatment plan. The treatment plan required shall include, but is not limited to, a diagnosis, the proposed treatment by type, the frequency and duration of treatment, the anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the signature of the treating physician. Coverage for these services shall be limited to $36,000 annually and may not exceed $200,000 in total benefits. 10.07.02 Coverage is subject to applicable Co-payments and coverage limitations as set forth in the Schedule of Benefits. ') } ) 10.08 Diagnostic imaging and laboratory. All prescribed diagnostic imaging and laboratory tests and services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and 23 A V -G 100-2009 MP-5319 (10/09)