As an exception to the Medically Necessary and Appropriate requirement of this Contract, We also provide coverage for the mother and newly born child for: a minimum of 48 hours of Inpatient care in a [Network] Hospital following a vaginal delivery; and a minimum of 96 hours of Inpatient care in a [Network] Hospital following a cesarean section. We provide childbirth and newborn coverage subject to the following: the attending Practitioner must determine that Inpatient care is medically necessary; or the mother must request the Inpatient care. [As an alternative to the minimum level of Inpatient care described above, the mother may elect to participate in a home care program provided by Us.] Private accommodations [will be provided only when approved in advance by Us]. If a [Member] occupies a private room without such approval [Member] shall be directly liable to the Hospice, Hospital, Rehabilitation Center or Skilled Nursing Facility for the difference between payment by Us to the Hospice, Hospital, Rehabilitation Center or Skilled Nursing Facility of the per diem or other agreed upon rate for semi-private accommodation established between Us and the [Network] Hospice, [Network] Hospital, [Network] Rehabilitation Center or [Network] Skilled Nursing Center and the private room rate. General nursing care Use of intensive or special care facilities X-ray examinations including CAT scans but not dental x-rays Use of operating room and related facilities Magnetic resonance imaging "MRI" Drugs, medications, biologicals Cardiography/Encephalography Laboratory testing and services Pre- and post-operative care Special tests Nuclear medicine Therapy Services Oxygen and oxygen therapy Anesthesia and anesthesia services Blood, blood products and blood processing Intravenous injections and solutions 19. Surgical, medical and obstetrical services. We also cover reconstructive breast Surgery, Surgery to restore and achieve symmetry between the two breasts and the cost of prostheses following a mastectomy on one breast or both breasts. We also cover treatment of the physical complications of mastectomy, including lymphedemas. We also cover surgical treatment of morbid obesity for one surgical procedure within a two-year period, measured from the date of the first surgical procedure to treat morbid obesity, unless a multi-stage procedure is planned and We authorize coverage for such
dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by specialist or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted if a stand-alone dental plan is bought. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision. [Additional benefits for a Child under age 6] For a Member who is severely disabled or who is a Child under age 6, We cover: general anesthesia and Hospitalization for dental services; and