Common use of Dialysis Services Clause in Contracts

Dialysis Services. Dialysis services for chronic renal failure are covered when provided in a Hospital, an outpatient facility or in the home. Pre-Authorization is required for dialysis performed in an outpatient facility or at home. Durable Medical Equipment Durable Medical Equipment (“DME”) is Medical Equipment, including mobility enhancing equipment that can withstand repeated use, is not disposable, is used for a medically therapeutic purpose, is generally not useful in the absence of Illness or Injury, and is appropriate for use in the home. DME may be rented or purchased at the discretion of the plan; the total cost of any DME rental may not exceed the purchase price. Repair or replacement is covered only when needed due to normal use, a change in the patient’s physical condition, or the growth of a child. Duplicate items are not covered. When more than one option exists, benefits will be limited to the least expensive model or item appropriate to treat the patient’s covered condition. Examples of DME include: • Crutches; • Oxygen and equipment for administering oxygen; • Xxxxxxx; and • Wheelchairs. This benefit also covers: • Breast Pumps; • Diabetic monitoring equipment, such as the initial cost of an insulin pump and supplies related to such equipment. Diabetic supplies such as insulin, syringes, needles, lancets, test strips, etc., are covered under the Prescription Drugs benefit; • Medical supplies needed for the treatment or care of an appropriate covered condition, including but not limited to compression garments, mastectomy bras and supplies, and ostomy supplies. Please note that supplies available over-the-counter are excluded from this benefit; • Limited Medical Vision Hardware: Benefits are provided for vision hardware for the following medical conditions of the eye: corneal ulcer, bullous keratopathy, recurrent erosion of cornea, tear film insufficiency, aphakia, Xxxxxxxx's disease, congenital cataract, corneal abrasion and keratoconus; and • State sales tax for durable medical and mobility enhancing equipment. Surgically implanted devices may be covered under the appropriate surgical benefit and are not considered DME. Benefits for DME are determined by the type of device and its intended use, and not by the entity that provides or bills for the device. DME and medical supply charges listed below are not covered: • Biofeedback equipment; • Equipment or supplies whose primary purpose is preventing Illness or Injury; • Exercise equipment; • Eyeglasses or contact lenses for conditions not listed as a covered medical condition or covered under the Pediatric Vision benefit, including routine eye care; • Items not manufactured exclusively for the direct therapeutic treatment of an Illness or Injury; • Items primarily for comfort, convenience, sports/recreational activities or use outside the home; • Off-the shelf shoe inserts and orthopedic shoes; • Over-the-counter items (except Medically Necessary crutches, walkers, standard wheelchairs, diabetic supplies and ostomy supplies are covered); • Personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads, diapers, or personal hygiene items; • Phototherapy devices related to seasonal affective disorder; • Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, and modifications made to the patient’s home, place of work, or vehicle; or • The following Medical Equipment/supplies: regular or special car seats or strollers, push chairs, air filtration/purifier systems or supplies, water purifiers, allergenic mattresses, orthopedic or other special chairs, pillows, bed-wetting training equipment, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except diabetic equipment and supplies, and home anticoagulation meters). Emergency Care Services This plan covers Emergency Care services, including supplies, outpatient charges for patient observation, Facility costs, and medical screening exams that are required for the stabilization of a patient experiencing a Medical Emergency. Emergency Care services provided by In-Network and Out-of-Network facilities are covered by this plan and include Medically Necessary detoxification services, including Chemical Dependency detoxification. Prescription medications associated with a Medical Emergency, including those purchased in a foreign country, are also covered.