Page 55 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Reconstructive Procedures
Reconstructive procedures when the primary purpose of the procedure is either of the following:

• Treatment of a medical condition.
• Improvement or restoration of physiologic function.

Reconstructive procedures include surgery or other procedures which are related to an Injury, Sickness
or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical
appearance.
Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital
Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The
fact that you may suffer psychological consequences or socially avoidant behavior as a result of an Injury,
Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such
consequences or behavior) as a reconstructive procedure.
Please note that 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, are provided in the same manner and at the same level as those for any other Covered
Health Care Service. You can call the Claims Administrator at the telephone number on your ID card for
more information about Benefits for mastectomy-related services.

Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
Short-term outpatient rehabilitation services limited to:

• Physical therapy.
• Occupational therapy.

• Manipulative Treatment.

• Speech therapy.
• Pulmonary rehabilitation therapy.

• Cardiac rehabilitation therapy.
• 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. Rehabilitative services provided in your home other than by a
Home Health Agency are provided as described under this section.
Benefits can be denied or shortened when either of the following applies:

• You are not progressing in goal-directed rehabilitation services.
• Rehabilitation goals have previously been met.

Benefits are not available for maintenance/preventive treatment.
For outpatient rehabilitative services for speech therapy the Plan will pay Benefits for the treatment of
disorders of speech, language, voice, communication and auditory processing only when the disorder

52 Section 1: Covered Health Care Services