Prostheses. The Plan does not provide Benefits for dental prostheses, including implants that support mandibular prosthesis. The Plan does not provide Benefits for prosthetic devices to replace, in whole or in part, an arm or a leg, that are designed exclusively for athletic purposes or higher technology (e.g. titanium, microprocessor) than meets the Member’s medical needs. Covered prostheses described in section 4.B.8 and 4.B.22 are Covered under the Plan. No other prostheses are covered.
Prostheses. Internal and external prostheses required to replace a body part are covered. Examples are artificial legs, surgically implanted hip joints, devices to restore speaking after laryngectomy and visual aids (excluding Eyewear) to assist the visually impaired with proper dosing of insulin. Also covered are internally implanted devices such as heart pacemakers. In addition, prostheses to restore symmetry after a Medically Necessary mastectomy are covered. Health Net or your Physician Group will select the provider or vendor for the items. If two or more types of medically appropriate devices or appliances are available, Health Net or the contracting Physician Group will determine which device or appliance will be covered. The device must be among those that the Food and Drug Administration has approved for general use. Prostheses will be replaced when no longer functional. However, repair or replacement for loss or misuse is not covered. Health Net will decide whether to replace or repair an item. Second Opinion by a Physician You have the right to request a second opinion when: • Your Primary Care Physician or a referral Physician gives a diagnosis or recommends a treatment plan, that you are not satisfied with; • You are not satisfied with the result of treatment you have received; • You are diagnosed with, or a treatment plan is recommended for, a condition that threatens loss of life, limb or bodily function or a substantial impairment, including but not limited to a Serious Chronic Condi- tion; or • Your Primary Care Physician or a referral Physician is unable to diagnose your condition or test results are conflicting. To request an authorization for a second opinion, contact your Primary Care Physician or Health Net’s Customer Contact Center. Physicians at your Physician Group or Health Net will review your request in accordance with Health Net’s procedures and timelines as stated in the second opinion policy. You may obtain a copy of this policy from Health Net’s Customer Contact Center. All authorized second opinions must be provided by a Physician who has training and expertise in the illness, disease or condition associated with the request.
Prostheses. Internal and external prostheses required to replace a body part are covered. Examples are artificial legs, surgically implanted hip joints, devices to restore speaking after laryngectomy and visual aids (excluding eyewear) to assist the visually impaired with proper dosing of insulin. Also covered are internally implanted devices such as heart pacemakers. In addition, prostheses to restore symmetry after a Medically Necessary mastectomy are covered. The device must be among those that the Food and Drug Administration has approved for general use. If two or more types of medically appropriate devices are available, Health Net will determine which device or appliance will be covered. Prostheses will be replaced when no longer functional. However, repair or replacement for loss or misuse is not covered. Health Net will decide whether to replace or repair an item. Organ, Tissue and Stem Cell Transplants Organ, tissue and stem cell transplants that are not Experimental or Investigational are covered if the transplant is authorized under SELECT 1 or precertified under SELECT 2 by Health Net and performed at a Health Net Transplant Performance Center. Health Net has a specific network of designated Transplant Performance Centers to perform organ, tissue and stem cell transplants. Your Member Physician can provide you with information about our Transplant Performance Centers. You will be directed to a designated Health Net Transplant Performance Center at the time authorization or precertification is obtained. Preferred Providers that are not designated as part of Health Net’s network of Transplant Performance Centers are considered Out-of-Network Providers for purposes of determining coverage and benefits for transplants and transplant-related services. Medically Necessary services, in connection with an organ, stem cell or tissue transplant are covered as follows: For the enrolled Member who receives the transplant; and For the Donor (whether or not an enrolled Member). Benefits are reduced by any amounts paid or payable by the donor’s own coverage. Only Medically Necessary services related to the organ donation are covered. Evaluation of potential candidates is subject to prior authorization. More than one evaluation (including tests) at more than one transplant center will not be authorized unless it is determined to be Medically Necessary. Organ donation extends and enhances lives and is an option that you may want to consider. For more information on organ ...
Prostheses. Any expenses that specifically replace missing body parts including, but not limited to, artificial limbs, mammary prostheses, artificial eyes, intraocular lens implants or contact lenses after cataract surgery and colostomy supplies are not covered except as specifically stated. Exclusions and Limitations Page 81
Prostheses. The appropriate devices used to replace a body part missing because of an Accident, Injury, or Illness. When placement of a prosthesis is part of a surgical procedure, it will be paid under Surgical Services. Payment for deluxe prosthetics will be based on the Allowable Fee for a standard prosthesis. The Plan will not pay for the following items:
Prostheses. Internal and external prostheses required to replace a body part are covered. Examples are artificial legs, surgi- cally implanted hip joints, devices to restore speaking after a laryngectomy and visual aids (excluding eyewear) to assist the visually impaired with proper dosing of insulin. Also covered are internally implanted devices such as heart pacemakers. In addition, prostheses to restore symmetry after a Medically Necessary mastectomy (including lumpectomy), and prostheses to restore symmetry and treat complications, including lymphedema, are covered. Lymphedema wraps and garments are covered, as well as up to three brassieres in a 12 month period to hold a prostheses. In addition, enteral formula for members who require tube feeding is covered in accordance with Medicare guidelines. Health Net or the Member's Physician Group will select the provider or vendor for the items. If two or more types of medically appropriate devices or appliances are available, Health Net or the Physician Group will determine which device or appliance will be covered. The device must be among those that the Food and Drug Administra- tion has approved for general use. Prostheses will be replaced when no longer functional. However, repair or replacement for loss or misuse is not covered. Health Net will decide whether to replace or repair an item. Prostheses are covered as shown under "Medical Supplies" in "Schedule of Benefits and Copayments," Section 200. Blood Blood transfusions, including blood processing, the cost of blood, unreplaced blood and blood products, are covered. However, self-donated (autologous) blood transfusions are covered only for a surgery that the contract- ing Physician Group has authorized and scheduled. Inpatient Hospital Confinement Covered services include: • Accommodations as an inpatient in a room of two or more beds, at the Hospital's most common semi-private room rate with customary furnishings and equipment (including special diets as Medically Necessary); • Services in Special Care Units; • Private rooms, when Medically Necessary • Physician services • Specialized and critical care • General nursing care • Special duty nursing as Medically Necessary); • Operating, delivery and special treatment rooms; • Supplies and ancillary services including laboratory, cardiology, pathology, radiology and any professional component of these services; • Physical, speech, occupational and respiratory therapy; • Radiation therapy, chemotherapy and renal d...
Prostheses. An artificial extension that replaces a missing part of the body or sup- plements defective parts.
