Page 56 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

results from Injury, stroke, cancer or Congenital Anomaly. The Plan will pay Benefits for cognitive
rehabilitation therapy only when Medically Necessary following a post-traumatic brain Injury or stroke.

Scopic Procedures - Outpatient Diagnostic and Therapeutic
Diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a
Hospital or Alternate Facility or in a Physician's office.
Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of
diagnostic scopic procedures include:
• Colonoscopy.

• Sigmoidoscopy.
• Diagnostic Endoscopy.

Please note that Benefits do not include surgical scopic procedures, which are for the purpose of
performing surgery. Benefits for surgical scopic procedures are described under Surgery - Outpatient.

Benefits include:
• The facility charge and the charge for supplies and equipment.

• Physician services for radiologists, anesthesiologists and pathologists. (Benefits for all other
Physician services are described under Physician Fees for Surgical and Medical Services.)
Benefits that apply to certain preventive screenings are described under Preventive Care Services.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
Services and supplies provided during an Inpatient Stay in a Skilled Nursing Facility or Inpatient
Rehabilitation Facility. Benefits are available for:
• Supplies and non-Physician services received during the Inpatient Stay.

• Room and board in a Semi-private Room (a room with two or more beds).

• Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.)
Please note that Benefits are available only if both of the following are true:

• If the first confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be
a cost effective option to an Inpatient Stay in a Hospital.

• You will receive Skilled Care services that are not primarily Custodial Care.
The Claims Administrator will determine if Benefits are available by reviewing both the skilled nature of
the service and the need for Physician-directed medical management.
Benefits can be denied or shortened when either of the following applies:

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

53 Section 1: Covered Health Care Services