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suffer psychological consequences or socially avoidant behavior due to an Injury, Sickness or Congenital
Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a
reconstructive procedure.

Note: Benefits for reconstructive procedures include breast reconstruction following a mastectomy, and
reconstruction of the non-affected breast to achieve symmetry. Other services required by the Women's Health
and Cancer Rights Act of 1998, including breast prostheses and treatment of complications at all stages of
mastectomy including lymph edemas, are provided in the same manner and at the same level as those for any
other Covered Health Care Service.
Rehabilitation Services - Outpatient Therapy

Short-term outpatient rehabilitation services, including habilitative services, limited to:

· Physical therapy;
· Occupational therapy;

· Manipulative treatment (Chiropractic Care);
· Speech therapy;

· Pulmonary rehabilitation therapy;
· Cardiac rehabilitation therapy; and

· Post-cochlear implant aural therapy.
· Cognitive rehabilitation therapy

Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits include
rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital or Alternate Facility.
Rehabilitative services provided in your home by a Home Health Agency are provided as described under Home
Health Care.

Benefits can be denied or shortened when either of the following applies:
· You are not progressing in goal-directed rehabilitation services, or

· Rehabilitation goals have previously been met.
Benefits under this section are not available for maintenance/preventive Manipulative Treatment.

For outpatient rehabilitative services for speech therapy, we will pay Benefits for the treatment of disorders of
speech, language, voice, communication and auditory processing only when the disorder results from Injury,
stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorder.

Habilitative Services

Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you have a
disabling condition when both of the following conditions are met:

· The treatment is administered by a licensed speech-language pathologist, licensed audiologist, licensed
occupational therapist, licensed physical therapist, or Physician.
· The initial or continued treatment must be proven and not Experimental or Investigational.

Benefits for habilitative services do not apply to those services that are solely educational in nature or otherwise
paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic
recreation, vocational training and residential treatment are not habilitative services. A service that does not help
the Covered Person to meet functional goals in a treatment plan within a prescribed time frame is not a
habilitative service.
We may require that a treatment plan be provided, request medical records, clinical notes, or other necessary
data to allow us to prove that initial or continued medical treatment is needed. When the treating provider expects
that continued treatment is or will be required to allow you to achieve progress this is capable of being
demonstrated, we may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency,
expected duration of treatment, the expected goals of treatment, and how frequently the treatment plan will be
updated.

Page 32 Section 5- Additional Coverage Details
PPO - 2017