Rehabilitative Care—90%

The benefits described below are provided for rehabilitative care when prescribed by the patient'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 15 inpatient days. If charges for more than 15 inpatient days are submitted, those charges will be denied. 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, respiratory, or occupational therapist in the office, clinic or outpatient hospital department with an annual maximum of 30 outpatient visits. If charges for more than 30 outpatient visits are submitted, those charges will be denied. 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 (included in the annual 30 outpatient visit maximum) 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 (i.e., incontinence), and more conventional treatments (i.e., heat, cold, massage, exercise, and support) have not been successful.

Exercise programs for cardiac patients, commonly referred to as "cardiac rehabilitation," are covered within the provisions of the outpatient rehabilitative care benefit (included in the 30 outpatient visit annual maximum). Benefits are provided for phase II cardiac rehabilitation up to a maximum of 12 weeks or 30 sessions when provided by a hospital outpatient department or in a physician-directed clinic. Cardiac rehabilitation program benefits are available only for patients 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.

Inpatient or outpatient benefits are not provided for:

1. Custodial or maintenance 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.
2. Social or cultural therapy.
3. Acupressure or the services of a massage therapist.
4. Therapy prescribed by a chiropractor or a physical, speech, respiratory, or occupational therapist; or therapy elected by the patient but not prescribed by the attending physician prior to commencement of treatment.
5. 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.
6. 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.
7. 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.
8. Inpatient or outpatient rehabilitation received more than 12 months after the illness or injury onset date, or after the date of the surgery that made rehabilitation necessary.
9. Therapy to assist in the initial development of a motor or sensory skill including speech therapy for developmental disorders of articulation, except as provided for under "Neurodevelopmental Therapy"; self-correcting dysfunction such as hoarseness, language therapy for young children with natural dysfluency, or therapy to correct developmental or emotional language delays; oral myofunctional therapy; stammering and stuttering; tongue thrust; sensory integration therapy; state-required medical assessments for specialized educational programs; services or supplies required by law to be provided by any school system; treatment of learning disabilities or developmental delays; or feeding therapy. This exclusion applies regardless of the recommendation of the attending physician.
10. Biofeedback for muscle tension states, psychosomatic conditions, tension and anxiety states, headaches, chronic pain, Raynaud's disease, or hypertension.
11. Neurodevelopmental therapy, autism spectrum therapy, and rehabilitative care for the same condition.