Page 58 - Aegion Value Plan SPDs
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Sterilization
Sterilizations for women will be covered under the “Preventive Care” benefit. Please see that section in
Benefits for further details.
Mastectomy Notice
A Member who is receiving benefits for a covered mastectomy or for follow-up care in connection with a
covered mastectomy, and who elects breast reconstruction, will also receive coverage for:
reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance; and
prostheses and treatment of physical complications of all stages of mastectomy, including
lymphedemas.
This coverage will be provided in consultation with the patient and the patient’s attending physician and will
be subject to the same annual Deductible provisions otherwise applicable under the Plan.
Therapy Services
Coverage for Therapy Services when provided as part of Physician Office Services, Inpatient Facility
Services, Outpatient Services, or Home Care Services is limited to the following:
Physical Medicine Therapy Services
The expectation must exist that the therapy will result in a practical improvement in the level of functioning
within a reasonable period of time.
Physical therapy including treatment by physical means, hydrotherapy, heat, or similar modalities,
physical agents, bio-mechanical and neuro-physiological principles and devices. Such therapy is given
to relieve pain, restore function, and to prevent disability following illness, injury, or loss of a body part.
Speech therapy for the correction of speech impairment. The expectation must exist that the therapy
will result in a practical improvement in the level of function within a reasonable period of time.
Occupational therapy for the treatment of a physically disabled person by means of constructive
activities designed and adapted to promote the restoration of the person’s ability to satisfactorily
accomplish the ordinary tasks of daily living and those tasks required by the person’s particular
occupational role. Occupational therapy does not include diversional, recreational, vocational therapies
(e.g. hobbies, arts and crafts)
Spinal manipulation services to correct by manual or mechanical means structural imbalance or
subluxation to remove nerve interference from or related to distortion, misalignment or subluxation of
or in the vertebral column.
Other Therapy Services
Cardiac rehabilitation to restore an individual’s functional status after a cardiac event. Home
programs, on-going conditioning and maintenance are not covered.
Chemotherapy for the treatment of disease by chemical or biological antineoplastic agents, including
the cost of such agents.
Dialysis treatments of an acute or chronic kidney ailment which may include the supportive use of an
artificial kidney machine.
Radiation therapy for the treatment of disease by X-ray, radium, or radioactive isotopes.
Inhalation therapy for the treatment of a condition by the administration of medicines, water vapors,
gases, or anesthetics by inhalation.
Physical Medicine and Rehabilitation Services
A structured therapeutic program of an intensity that requires a multidisciplinary coordinated team approach
to upgrade the patient’s ability to function as independently as possible; including skilled rehabilitative
nursing care, physical therapy, occupational therapy, speech therapy and services of a social worker or
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Sterilizations for women will be covered under the “Preventive Care” benefit. Please see that section in
Benefits for further details.
Mastectomy Notice
A Member who is receiving benefits for a covered mastectomy or for follow-up care in connection with a
covered mastectomy, and who elects breast reconstruction, will also receive coverage for:
reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance; and
prostheses and treatment of physical complications of all stages of mastectomy, including
lymphedemas.
This coverage will be provided in consultation with the patient and the patient’s attending physician and will
be subject to the same annual Deductible provisions otherwise applicable under the Plan.
Therapy Services
Coverage for Therapy Services when provided as part of Physician Office Services, Inpatient Facility
Services, Outpatient Services, or Home Care Services is limited to the following:
Physical Medicine Therapy Services
The expectation must exist that the therapy will result in a practical improvement in the level of functioning
within a reasonable period of time.
Physical therapy including treatment by physical means, hydrotherapy, heat, or similar modalities,
physical agents, bio-mechanical and neuro-physiological principles and devices. Such therapy is given
to relieve pain, restore function, and to prevent disability following illness, injury, or loss of a body part.
Speech therapy for the correction of speech impairment. The expectation must exist that the therapy
will result in a practical improvement in the level of function within a reasonable period of time.
Occupational therapy for the treatment of a physically disabled person by means of constructive
activities designed and adapted to promote the restoration of the person’s ability to satisfactorily
accomplish the ordinary tasks of daily living and those tasks required by the person’s particular
occupational role. Occupational therapy does not include diversional, recreational, vocational therapies
(e.g. hobbies, arts and crafts)
Spinal manipulation services to correct by manual or mechanical means structural imbalance or
subluxation to remove nerve interference from or related to distortion, misalignment or subluxation of
or in the vertebral column.
Other Therapy Services
Cardiac rehabilitation to restore an individual’s functional status after a cardiac event. Home
programs, on-going conditioning and maintenance are not covered.
Chemotherapy for the treatment of disease by chemical or biological antineoplastic agents, including
the cost of such agents.
Dialysis treatments of an acute or chronic kidney ailment which may include the supportive use of an
artificial kidney machine.
Radiation therapy for the treatment of disease by X-ray, radium, or radioactive isotopes.
Inhalation therapy for the treatment of a condition by the administration of medicines, water vapors,
gases, or anesthetics by inhalation.
Physical Medicine and Rehabilitation Services
A structured therapeutic program of an intensity that requires a multidisciplinary coordinated team approach
to upgrade the patient’s ability to function as independently as possible; including skilled rehabilitative
nursing care, physical therapy, occupational therapy, speech therapy and services of a social worker or
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