Page 122 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Substance-Related and Addictive Disorders Services - services for the diagnosis and treatment of
alcoholism and substance-related and addictive disorders that are listed in the current edition of the
International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and
Statistical Manual of the American Psychiatric Association. The fact that a disorder is listed in the current
edition of the International Classification of Diseases section on Mental and Behavioral Disorders or
Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment
of the disorder is a Covered Health Care Service.
Summary Material Modification (SMM) - any attached written description of additional Covered Health
Care Services not described in this SPD. Covered Health Care Services provided by a SMM may be
subject to payment of additional Service Fees. SMMs are subject to all conditions, limitations and
exclusions of the Plan except for those that are specifically amended in the SMM.

Surrogate - a female who becomes pregnant usually by artificial insemination or transfer of a fertilized
egg (embryo) for the purpose of carrying the fetus for another person. When the surrogate provides the
egg the surrogate is biologically (genetically) related to the child.
Transitional Living - Mental health care services and substance-related and addictive disorders services
provided through facilities, group homes and supervised apartments which provide 24-hour supervision,
including those defined in the American Society of Addiction Medicine (ASAM) Criteria and are either:
• Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. They provide
stable and safe housing, an alcohol/drug-free environment and support for recovery. They may be
used as an addition to ambulatory treatment when it doesn't offer the intensity and structure
needed to help you with recovery.
• Supervised living arrangements which are residences such as facilities, group homes and
supervised apartments. They provide stable and safe housing and the opportunity to learn how to
manage activities of daily living. They may be used as an addition to treatment when it doesn't offer
the intensity and structure needed to help you with recovery.

Unproven Service(s) - services, including medications, that are determined not to be effective for
treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to
insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort
studies in the prevailing published peer-reviewed medical literature.

• Well-conducted randomized controlled trials. (Two or more treatments are compared to each other,
and the patient is not allowed to choose which treatment is received.)

• Well-conducted cohort studies from more than one institution. (Patients who receive study
treatment are compared to a group of patients who receive standard therapy. The comparison
group must be nearly identical to the study treatment group.)
The Claims Administrator has a process by which the Claims Administrator compiles and reviews clinical
evidence with respect to certain health care services. From time to time, the Claims Administrator issues
medical and drug policies that describe the clinical evidence available with respect to specific health care
services. These medical and drug policies are subject to change without prior notice. You can view these
policies at www.myuhc.com.
Please note:

• If you have a life-threatening Sickness or condition (one that is likely to cause death within one year
of the request for treatment) the Claims Administrator may, as the Claims Administrator
determines, consider an otherwise Unproven Service to be a Covered Health Care Service for that
Sickness or condition. Prior to such a consideration, the Claims Administrator must first establish
that there is sufficient evidence to conclude that, even though unproven, the service has significant
potential as an effective treatment for that Sickness or condition.

119 Section 9: Defined Terms