Rehabilitative
Care – 90%
The
benefits described below are provided for rehabilitative care when prescribed by
the individual’s attending physician and medically necessary to improve or
restore function previously normal but lost due to illness, injury or surgery.
Benefits are provided only for services and supplies received within 12 months
from the onset of the illness or injury or from the date of the surgery that
made rehabilitation necessary. If treatment is received 12 months after the
illness or injury onset date, this plan will not pay the costs.
Inpatient
Rehabilitative Care
Benefits are provided for a
semiprivate room in a hospital with a rehabilitation department or a
rehabilitation hospital. Inpatient admissions are covered for physical, speech,
respiratory, and occupational therapy services and supplies, with an annual
maximum of $24,000. If expenses exceed this $24,000 annual maximum, this plan
will not pay the additional costs. This benefit maximum includes physician
visits, medical supplies and the services of the physical, speech, respiratory,
and occupational therapist. All care must be part of a written plan of
multidisciplinary treatment prescribed and periodically reviewed by the
attending physician.
Preadmission
certification is required for a separate inpatient admission or for an admission
that is part of a continuous inpatient stay that began with acute care.
Inpatient care is
only covered when services cannot be provided in a less intensive
setting.
Outpatient
Rehabilitative Care
Benefits are provided for
physical, speech, respiratory, and occupational therapy when performed by a
physician or physical, speech or occupational therapist in the office, clinic or
outpatient hospital department, with an annual maximum of $2,000. If expenses
exceed this $2,000 annual maximum, this plan will not pay the additional costs.
All outpatient rehabilitation must be part of a formal program prescribed by the
attending physician. Therapy must be provided under the physician’s
supervision and the patient must continue under the care of the physician during
the time the therapy is provided. In addition, the physician must periodically
evaluate the treatment plan and certify that continuing therapy is required. The
initial claim must be submitted with the physician’s prescription for the
rehabilitative care.
Biofeedback
is covered within the provisions of the outpatient rehabilitative care benefit
but only when it is reasonable and necessary for muscle reeducation of specific
muscle groups or for treating pathological muscle abnormalities of spasticity,
incapacitating muscle spasm or weakness (e.g., incontinence), and more
conventional treatments (e.g., heat, cold, massage, exercise, and support) have
not been successful. Biofeedback is not covered for services including, but not
limited to, muscle tension states, psychosomatic conditions, tension and anxiety
states, headaches, insomnia, movement disorders, chronic pain, Raynaud’s
disease, or hypertension.
Exercise
programs for cardiac patients, commonly referred to as “cardiac
rehabilitation,” are covered within the provisions of the outpatient
rehabilitative care benefit. Benefits are provided for phase II cardiac
rehabilitation up to a maximum of 12 weeks or 36 sessions when provided by a
hospital outpatient department or in a physician-directed clinic. Cardiac
rehabilitation program benefits are available only for individuals with a clear
medical need who are referred by their attending physician and (1) have a
documented diagnosis of acute myocardial infarction within the preceding 12
months, or (2) have had coronary bypass surgery, or (3) have stable angina
pectoris. Phase III cardiac rehabilitation is
not
covered.
Benefits
are not
provided for (inpatient or
outpatient):
- Custodial
care; nonmedical self-help or related testing; work hardening; recreational,
educational, cognitive, behavioral, or vocational therapy; neuromuscular
reevaluation; gym or pool therapy; or therapy or maintenance which is solely for
the purpose of slowing body degeneration rather than restoring functional
improvement.
- Social
or cultural therapy.
- Acupressure,
neurofeedback or services of a massage therapist.
- Therapy
prescribed by a chiropractor or a physical, speech, respiratory, or occupational
therapist; or therapy elected by you or a dependent but not prescribed by the
attending physician prior to commencement of treatment.
- Services
related to activities intended to promote overall fitness, sports conditioning
or overuse, flexibility or sense of well being without direct relationship to
restoration of a functional loss related to illness, injury or
surgery.
- Repetitive
exercises to improve or maintain gait or strength and endurance; range of motion
and passive exercises not related to restoration of a specific loss of function
but useful only in maintaining range of motion in paralyzed extremities; and
assisted walking such as that provided in support for feeble or unstable
patients.
- Maintenance
provided to patients who have achieved their therapeutic goals; or maintenance
therapy provided to patients whose progress in strength and mobility has reached
a plateau.
- Inpatient
or outpatient rehabilitation received more than 12 months from the illness or
injury onset date or from the date of the surgery that made rehabilitation
necessary.
- Therapy
to assist in the initial development of a motor or sensory skill including
speech therapy for self-correcting dysfunction, such as hoarseness or language
therapy for young children with natural dysfluency; oral myofunctional therapy;
stammering and stuttering; or tongue thrust.
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