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() ') o ) ) 10.09 ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or injury or as preventive health care services. Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADHD). Coverage is subject to applicable Co-payments and coverage limitations as outlined on the Schedule of Benefits. Covered services do not include those that are primarily educational or training in nature. Durable Medical Equipment (DME). This Contract provides benefits, when Medically Necessary, for the purchase or rental of such DME that: 10.10 10.10.01 10.10.02 10.10.03 10.10.04 Can withstand repeated use (I.e. could normally be rented and used by successive patients); Is primarily and customarily used to serve a medical purpose; Generally is not useful to a person in the absence of illness or injury; and Is appropriate for use in a patient's home. 10.10.05 Some examples of DME are: hospital beds, crutches, canes, walkers, wheelchairs, oxygen, respiratory equipment, apnea monitors and insulin pumps. It does not include hearing aids or corrective lenses, or the professional fee for fitting same. It also does not include medical supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay for rental of equiprnent up to the purchase price. Repair and/or replacements are not covered. 10.10.06 Oxygen is covered when Medically Necessary pursuant to AvMed's coverage guidelines, which are available free of charge upon request. The type of oxygen delivery system covered (stationary, portable, ambulatory) is based on the Member's activity status. Initial coverage is contingent upon arterial blood gas results. Reassessment of oxygen needs through pulse oximetry at rest and after exercise is required and must be performed by an independent respiratory provider at 3 months after the initiation of therapy and then yearly in order to re-qualify coverage of oxygen therapy. 10.10.07 The determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based upon its classification as defIDed by the Centers for Medicare and Medicaid Services. See Schedule of Benefits for any Co-payments or Limitations. See Part XII for Exclusions. 10.11 Emergency services. AvMed will cover all necessary physician and Hospital Services for Emergency Medical Services and Care. See Part 111, Sections 3.16 and 3.17. In the event Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may elect to transfer the Member to a participating provider as soon as it is medically appropriate to do so. If the Member chooses to stay in the Non-participating facility after the date AvMed decides a transfer is medically appropriate, out-of-network benefits may be available if the continued stay is determined to be a covered health service. In addition, any Member requests for reimbursernent (of payment made by the Member for services rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Claimant was legally incapacitated. 10.12 General anesthesia and hospitalization services to a Member who is under 8 years of age and is determined by a licensed dentist and the Member's physician to require necessary dental treatment in a Hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or iftbe Member has one or more medical conditions that would create significant or undue medical risk for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in 24 A V -Gl 00-2009 MP-53 19 (10/09)