Page 63 - Aegion Value Plan SPDs
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Covered orthotic devices include, but are not limited to, the following:
1. Cervical collars;
2. Ankle foot orthosis;
3. Corsets (back and special surgical);
4. Splints (extremity);
5. Trusses and supports;
6. Slings;
7. Wristlets;
8. Built-up shoe;
9. Custom made shoe inserts.
Orthotic appliances may be replaced once per year per Member when Medically Necessary in the
Member’s situation. However, additional replacements will be allowed for Members under age 18 due to
rapid growth, or for any Member when an appliance is damaged and cannot be repaired.
Non-Covered Services include but are not limited to:
1. Orthopedic shoes;
2. Foot support devices, such as arch supports and corrective shoes, unless they are an integral part
of a leg brace;
3. Standard elastic stockings, garter belts, and other supplies not specially made and fitted (except
as specified under Medical Supplies);
4. Garter belts or similar devices.
Accident Related Dental Services
Outpatient Services, Physician Office Services, Emergency Care and Urgent Care services for dental work
and oral surgery are covered if they are for the initial repair of an injury to the jaw, sound natural teeth,
mouth or face which are required as a result of an accident and are not excessive in scope, duration, or
intensity to provide safe, adequate, and appropriate treatment without adversely affecting the patient’s
condition. Injury as a result of chewing or biting is not considered an accidental injury except where the
chewing or biting results from an act of domestic violence or directly from a medical condition. Treatment
must be completed within the timeframe shown in the Schedule of Benefits. For a child requiring facial
reconstruction due to dental related injury, there may be several years between the accident and the final
repair.
Covered Services for accidental dental include, but are not limited to:
oral examinations;
x-rays;
tests and laboratory examinations;
restorations;
prosthetic services;
oral surgery;
mandibular/maxillary reconstruction;
anesthesia.
Maternity Care and Reproductive Health Services
Covered Services are provided for Network Maternity Care subject to the benefit stated in the Schedule of
Benefits. If You choose an Out-of-Network Provider, benefits are subject to the Deductible and percentage
payable provisions as stated in the Schedule of Benefits.
Routine newborn nursery care is part of the mother’s maternity benefits. Benefits are provided for well-
baby pediatrician visits performed in the Hospital.
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1. Cervical collars;
2. Ankle foot orthosis;
3. Corsets (back and special surgical);
4. Splints (extremity);
5. Trusses and supports;
6. Slings;
7. Wristlets;
8. Built-up shoe;
9. Custom made shoe inserts.
Orthotic appliances may be replaced once per year per Member when Medically Necessary in the
Member’s situation. However, additional replacements will be allowed for Members under age 18 due to
rapid growth, or for any Member when an appliance is damaged and cannot be repaired.
Non-Covered Services include but are not limited to:
1. Orthopedic shoes;
2. Foot support devices, such as arch supports and corrective shoes, unless they are an integral part
of a leg brace;
3. Standard elastic stockings, garter belts, and other supplies not specially made and fitted (except
as specified under Medical Supplies);
4. Garter belts or similar devices.
Accident Related Dental Services
Outpatient Services, Physician Office Services, Emergency Care and Urgent Care services for dental work
and oral surgery are covered if they are for the initial repair of an injury to the jaw, sound natural teeth,
mouth or face which are required as a result of an accident and are not excessive in scope, duration, or
intensity to provide safe, adequate, and appropriate treatment without adversely affecting the patient’s
condition. Injury as a result of chewing or biting is not considered an accidental injury except where the
chewing or biting results from an act of domestic violence or directly from a medical condition. Treatment
must be completed within the timeframe shown in the Schedule of Benefits. For a child requiring facial
reconstruction due to dental related injury, there may be several years between the accident and the final
repair.
Covered Services for accidental dental include, but are not limited to:
oral examinations;
x-rays;
tests and laboratory examinations;
restorations;
prosthetic services;
oral surgery;
mandibular/maxillary reconstruction;
anesthesia.
Maternity Care and Reproductive Health Services
Covered Services are provided for Network Maternity Care subject to the benefit stated in the Schedule of
Benefits. If You choose an Out-of-Network Provider, benefits are subject to the Deductible and percentage
payable provisions as stated in the Schedule of Benefits.
Routine newborn nursery care is part of the mother’s maternity benefits. Benefits are provided for well-
baby pediatrician visits performed in the Hospital.
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