Page 63 - Aegion PPO SPDs
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i. The Experimental/Investigative item, device, or service; or
ii. Items and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
diagnostic Services
diagnostic services are tests or procedures generally performed when You have specific symptoms, to
detect or monitor Your condition. Coverage for diagnostic Services, including when provided as part of
Preventive Care Services and Physician Office Services, Inpatient Services, Outpatient Services, Home
Care Services, and Hospice Services includes but is not limited to:
X-ray and other radiology services, including mammograms for any person diagnosed with breast
disease;
Magnetic Resonance Imaging (MRI);
CAT scans;
Laboratory and pathology services;
Cardiographic, encephalographic, and radioisotope tests;
Ultrasound services;
Allergy tests;
Electrocardiograms (EKG);
Electromyograms (EMG) except that surface EMG’s are not Covered Services;
Echocardiograms;
Bone density studies;
Positron emission tomography (PET scanning).
Central supply (IV tubing) or pharmacy (dye) necessary to perform tests is covered as part of the test,
whether performed in a Hospital or Physician’s office.
Surgical Services
Coverage for Surgical Services when provided as part of Physicians Office Services, Inpatient Services, or
Outpatient Services includes but is not limited to:
Performance of generally accepted operative and other invasive procedures;
The correction of fractures and dislocations;
Anesthesia (including services of a Certified Registered Nurse Anesthetist) and surgical assistance
when Medically Necessary;
Usual and related pre-operative and post-operative care; and
Other procedures may be approved from time to time.
The surgical fee includes normal post-operative care. The Plan may combine the reimbursement when
more than one surgery is performed during the same operative session. Contact the Claims Administrator
for more information.
Covered Surgical Services include, but are not limited to:
Operative and cutting procedures;
Endoscopic examinations, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Other invasive procedures such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or
spine.
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ii. Items and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
diagnostic Services
diagnostic services are tests or procedures generally performed when You have specific symptoms, to
detect or monitor Your condition. Coverage for diagnostic Services, including when provided as part of
Preventive Care Services and Physician Office Services, Inpatient Services, Outpatient Services, Home
Care Services, and Hospice Services includes but is not limited to:
X-ray and other radiology services, including mammograms for any person diagnosed with breast
disease;
Magnetic Resonance Imaging (MRI);
CAT scans;
Laboratory and pathology services;
Cardiographic, encephalographic, and radioisotope tests;
Ultrasound services;
Allergy tests;
Electrocardiograms (EKG);
Electromyograms (EMG) except that surface EMG’s are not Covered Services;
Echocardiograms;
Bone density studies;
Positron emission tomography (PET scanning).
Central supply (IV tubing) or pharmacy (dye) necessary to perform tests is covered as part of the test,
whether performed in a Hospital or Physician’s office.
Surgical Services
Coverage for Surgical Services when provided as part of Physicians Office Services, Inpatient Services, or
Outpatient Services includes but is not limited to:
Performance of generally accepted operative and other invasive procedures;
The correction of fractures and dislocations;
Anesthesia (including services of a Certified Registered Nurse Anesthetist) and surgical assistance
when Medically Necessary;
Usual and related pre-operative and post-operative care; and
Other procedures may be approved from time to time.
The surgical fee includes normal post-operative care. The Plan may combine the reimbursement when
more than one surgery is performed during the same operative session. Contact the Claims Administrator
for more information.
Covered Surgical Services include, but are not limited to:
Operative and cutting procedures;
Endoscopic examinations, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Other invasive procedures such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or
spine.
63
