Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

1 a Hospital or amhulatory surgical center. Pre-authorization by AvMed is required. There is no coverage for diagnosis or treatment of dental disease. 10.13 Hospital care: inpatient. All Hospital inpatient services received at Participating Hospitals for non- mental illness or injury are provided when prescribed by Participating Physicians and pre-authorized by AvMed. Inpatient services include semi-private room and board, birthing rooms, newborn nursery care, nursing care, meals and special diets when Medically Necessary, use of operating rooms and related facilities, the intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests, medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory therapy, and administration of blood or blood plasma. See Section 10.11 with regard to inpatient admission following Emergency Medical Services and Care. 10 .14 Hospice services. Services are available from a participating Hospice organization for a Mernber whose Participating Physician has determined the Member's illness will result in a remaining life span of 6 months or less. 10.15 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as associated immunosuppressant medications are covered except those deemed experimental. See Section 12.14. ') ,) 10.16 Mammograms are covered in accordance with Florida Statutes. One baseline mammogram is covered for female Members between the ages of 35 and 39. A mammogram is available every 2 years for female Mernbers between the ages of 40 and 49 and a manunogram is available every year for female Members aged 50 and older. 10.16.01 In addition, one or more mamrnograrns a year are available when based upon a physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who bas had breast cancer, or because a woman has not given birth before the age of30. 10.17 Mastectomy surgery when performed for breast cancer. Coverage for post-mastectomy reconstructive surgery shall include: ) Reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction on the other breast to produce a symmetrical appearance; and Prostheses and physical complications during all stages of mastectomy including Iymphedemas. The length of stay will not be less than that determined by the Attending Physician to be Medically Necessary in accordance with prevailing rnedical standards and after consultation with the covered patient. The Attending Physician, after consultation with the covered patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician's office, outpatient center, or home of the covered patient. 10.17.05 Coverage is subject to any applicable Co-payrnents and will require pre-authorization of services as applicable to other surgical procedures or hospitalizations under the Plan. 10.18 Newborn care. All services applicable for children under this Contract are covered for an enrolled newborn child of the Subscriber or the enrolled newborn child ofa covered Dependent of the Subscriber or the newborn adopted child of the Subscriber (as described in Subsection 4.02.02 (i)), from the moment of birth, including the Medically Necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or prematurity, and transportation costs to the nearest facility 10.17.01 10.17.02 10.17.03 10.17.04 25 A V-0100-2009 MP-5319 (10/09)