Page 44 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• The study or investigation takes place under an investigational new drug application reviewed by
the U.S. Food and Drug Administration.

• The study or investigation is a drug trial that is exempt from having such an investigational new
drug application.

• The clinical trial must have a written protocol that describes a scientifically sound study. It must
have been approved by all relevant institutional review boards (IRBs) before you are enrolled in the
trial. The Claims Administrator may, at any time, request documentation about the trial.
• The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Health Care Service and is not otherwise excluded under the Plan.

Congenital Heart Disease (CHD) Surgeries

CHD surgeries which are ordered by a Physician. CHD surgical procedures include surgeries to treat
conditions such as:

• Coarctation of the aorta.
• Aortic stenosis.

• Tetralogy of fallot.
• Transposition of the great vessels.

• Hypoplastic left or right heart syndrome.
Benefits include the facility charge and the charge for supplies and equipment. Benefits for Physician
services are described under Physician Fees for Surgical and Medical Services.
Surgery may be performed as open or closed surgical procedures or may be performed through
interventional cardiac catheterization.
You can call the Claims Administrator at the telephone number on your ID card for information about the
Claims Administrator's specific guidelines regarding Benefits for CHD services.

Dental Services - Accident Only

Dental services when all of the following are true:
• Treatment is needed because of accidental damage.
• You receive dental services from a Doctor of Dental Surgery or Doctor of Medical Dentistry.

• The dental damage is severe enough that first contact with a Physician or dentist happened within
72 hours of the accident. (You may request this time period be longer if you do so within 60 days of
the Injury and if extenuating circumstances exist due to the severity of the Injury.)
Please note that dental damage that happens as a result of normal activities of daily living or
extraordinary use of the teeth is not considered an accidental Injury. Benefits are not available for repairs
to teeth that are damaged as a result of such activities.

Dental services to repair damage caused by accidental Injury must follow these time-frames:
• Treatment is started within three months of the accident, or if not a Covered Person at the time of
the accident, within the first three months of coverage under the Plan, unless extenuating
circumstances exist (such as prolonged hospitalization or the presence of fixation wires from
fracture care).

41 Section 1: Covered Health Care Services