Page 29 - QCS.19 SPD - PPO

Diabetes Services

Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care
Outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy
services. Services must be ordered by a Physician and provided by appropriately licensed or registered
healthcare professionals.
Benefits also include medical eye exams (dilated retinal exams) and preventive foot care for diabetes.

Diabetic Self-Management Items

Insulin pumps and supplies for the management and treatment of diabetes, based upon your medical needs
including, but not limited to the following:

· Continuous blood glucose monitors;
· Insulin syringes with needles;

· Blood glucose and urine test strips;
· Ketone test strips and tablets; or

· Lancets and lancet devices.
Insulin pumps are subject to all the conditions of coverage stated under Durable Medical Equipment (DME),
Orthotics and Supplies and Ostomy supplies.

Durable Medical Equipment (DME), Orthotics and Supplies and Ostomy
Supplies

Benefits are provided for DME and certain orthotics and supplies.
If more than one item can meet your functional needs, Benefits are available only for the item that meets the
minimum specifications for your needs. If you purchase an item that exceeds these minimum specifications, we
will pay only that amount we would have paid for the item that meets the minimum specifications, and you will be
responsible for paying any difference in cost.
Examples of DME and supplies include:

· Equipment to help mobility, such as a walker, cane, or standard wheelchair;

· A standard hospital-type bed;
· Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks);
· External cochlear devices and systems. Surgery to place a cochlear implant is also covered by the Plan.
Cochlear implantation can either be an inpatient or outpatient procedure.
· Braces that stabilize an injured body part, including necessary adjustments to shoes to accommodate
braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are
considered Durable Medical Equipment and are a Covered Health Service. Braces that straighten or
change the shape of a body part are orthotic devices, and are excluded from coverage, unless prescribed
by a Physician. Dental braces are also excluded from coverage;

· Mechanical equipment needed for the treatment of long term or sudden respiratory failure (except that
air–conditioners, humidifiers, dehumidifiers, air purifiers and filters, and personal comfort items are
excluded from coverage);

· Burn garments; and
· Insulin pumps and all related needed supplies as described under Diabetes Services.

Benefits include lymphedema stockings for the arms as required by the Women's Health and Cancer Rights Act
of 1998.
Benefits do not include any device, appliance, pump machine, stimulator, or monitor that is fully implanted into
the body.

Page 24 Section 5- Additional Coverage Details
PPO - 2017