Reso 2010-1529 - Laserfiche WebLink

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) The rights of Members and obligations of Participating Providers hereunder are subject to the following Limitations: 11.01 Cardiac rehabilitation. Coverage is limited to a maximum of 18 visits per calendar year. 11.02 Diagnosis and treatment of Antism Spectrnm Disorder. Coverage for the diagnosis and treatment of Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total benefits. 11.03 HOl)le Health Care Services (Skilled Home Healtb Care) visits are limited to a period of 2 hours or less. 11.04 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines, subject to applicable Co-payments as listed for physical, speech and occupational therapies. 11.05 Licensed dietitians/nntritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes, renal disease or obesity control shall be limited to 3 outpatient visits per calendar year and each visit requires a Co-payment. See Schedule of Benefits and also Section 12.17. 11.06 Ortbotic appliances. Coverage for orthotic appliances is limited to custorn-made leg, arm, back and neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when necessary to carry out normal activities of daily living, excluding sports activities. 11.07 Otber Health Care Facility(ies). All routine inpatient services of other health care facilities (see Section 3.35), including physician visits, physiotherapy, diagnostic imaging and lahoratory work, are covered for a maxirnum of 20 days per calendar year when a Member is admitted to such a facility, following discharge from a Hospital, for a condition that cannot be adequately treated with Horne Health Care Services or on an ambulatory basis. 11.08 Physical, occupational or speech therapy. Physical, occupational or speech therapies shall be limited as explained in Sections 10.28 and 10.3. 11.09 Prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. 11.10 Second medical opinions. AvMed rnay lirnit second medical opinions in connection with a particular diagnosis or treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable over-utilization by the Mernber. 11.11 Speech therapy. Coverage is limited to 24 visits per calendar year including evaluations. 11.12 Snbstance ahnse - Hospital Lirnitation. Inpatient services for alcohol and drug abuse"shall be provided but only for acute detoxification and the treatment of other medical sequelae of such abuse. Inpatient alcohol or drug rehabilitation services are not covered. 11.13 Snpplies. Provision of ostomy and urostomy supplies are limited to a one-rnonth supply every 30 days. Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and Co-Insurance. 11.14 Ventilator dependent care. The total benefit for ventilator dependent care is limited to 100 calendar days lifetime maximum. 11.15 Transplant services. Transportation benefits for transplant services are administered through Opium Health, an AvMed third party partner. Benefits are limited to $200 per day up to $10,000 lifetime maximum for a companion to accompany the Member (or 2 companions when the patient is a minor) and the rnember has to travel greater than a 50 mile radius to receive the transplant. This is a henefit available only when the transplant is authorized at one of AvMed's transplant contracted facilities nationwide. ) ) 29 A V -0 I 00-2009 MP-5319 (10/09)