Page 57 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Spine and Joint Surgeries
Benefits for spine and joint surgeries which are ordered by a Physician. Spine and joint surgical
procedures include the following:
• Spine fusion surgery.

• Spine disc surgery.
• Total knee replacement.

• Total hip replacement.

Surgery - Outpatient

Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a
Physician's office.

Benefits include certain scopic procedures. Examples of surgical scopic procedures include:
• Arthroscopy.

• Laparoscopy.
• Bronchoscopy.

• Hysteroscopy.
Examples of surgical procedures performed in a Physician's office are mole removal and ear wax
removal.
Benefits include:

• The facility charge and the charge for supplies and equipment.
• Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.)

Temporomandibular Joint (TMJ) Services

Services for the evaluation and treatment of TMJ and associated muscles.
Diagnosis: Exam, radiographs and applicable imaging studies and consultation.
Coverage includes the following:

• Surgical treatment of the fractures and dislocations of the jaw or for treatment of accidental injury
to sound natural teeth, including replacement of such teeth, within 24 months after the date of an
accident.
• Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and roof of
the mouth.
• Removal of non-odontogenic lesions, tumors or cysts.

• Incision and drainage of non-odontogenic cellulitis.
• Surgery on accessory sinuses, salivary glands, ducts and tongue.

• Orthognathic surgery.

54 Section 1: Covered Health Care Services