the date the person first becomes a Dependent.] DEVELOPMENTAL DISABILITY or DEVELOPMENTALLY DISABLED. A severe, chronic disability that: is attributable to a mental or physical impairment or a combination of mental and physical impairments; is manifested before the [Member] attains age 26. is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency; reflects the [Member’s] need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to intellectual disability, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met. DIAGNOSTIC SERVICES. Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to: radiology, ultrasound, and nuclear medicine; laboratory and pathology; and EKG's, EEG's, and other electronic diagnostic tests. DISCRETION / DETERMINATION / DETERMINE. Our right to make a decision or determination. The decision will be applied in a reasonable and non-discriminatory manner. DURABLE MEDICAL EQUIPMENT. Equipment We Determine to be: designed and able to withstand repeated use; used primarily and customarily for a medical purpose; is generally not useful to a[Member] in the absence of an Illness or Injury; and suitable for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, breathing equipment, hospital-type beds, walkers, and wheelchairs as well as hearing aids which are covered through age 15. Items such as walkers, wheelchairs and hearing aids are examples durable medical equipment that are also habilitative devices. Among other things, Durable Medical Equipment does not include: adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to a[Member]'s home or place of business, waterbeds, whirlpool baths, exercise and massage equipment.
schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism. The current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association may be consulted to identify conditions that are considered Mental Illness. [NETWORK] PROVIDER. A Provider which has an agreement [directly or indirectly] with Us to provide Covered Services or Supplies. The Employee will have access to lists of [Network] Providers. [NEWLY ACQUIRED DEPENDENT. An eligible Dependent an Employee acquires after he or she already has coverage in force for Initial Dependents.] NON-COVERED SERVICES. Services or supplies which are not included within Our definition of Covered Services or Supplies, are included in the list of Non-Covered Services and Supplies, or which exceed any of the limitations shown in this Contract. NON- [NETWORK] PROVIDER. A Provider which is not a [Network] Provider. [NON-PREFERRED DRUG. A drug that has not been designated as a Preferred Drug.] NURSE. A registered nurse or licensed practical nurse, including a nursing specialist such as a nurse mid-wife or nurse anesthetist, who: is properly licensed or certified to provide medical care under the laws of the state where the nurse practices; and provides medical services which are within the scope of the nurse's license or certificate. [ORIENTATION PERIOD. A period of no longer than one month during which the employer and employee determine whether the employment situation is satisfactory for each party and any necessary orientation and training processes commence. As used in this definition, one month is determined by adding one calendar month and subtracting one calendar day, measured from an Employee’s start date in a position that is otherwise eligible for coverage. Refer to 26 C.F.R. 54.9815-2708(c)(iii).] ORTHOTIC APPLIANCE. A brace or support but does not include fabric and elastic supports, corsets, arch supports, trusses, elastic hose, canes, crutches, cervical collars, dental appliances or other similar devices carried in stock and sold by drug stores, department stores, corset shops or surgical supply facilities. OUTPATIENT. [Member], if not confined as a registered bed patient in a Hospital or recognized health care Facility and is not an Inpatient; or services and supplies provided in such Outpatient settings.
Inlay/onlay restorations – metallic, service includes local anesthesia, cementation, polishing and adjusting occlusion but only covered if the place of service is a teaching institution or residency program Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Service requires prior authorization and will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor long term prognosis Service includes local anesthesia, temporary crown placement, insertion with cementation, polishing and adjusting occlusion. Provisional crowns are not covered. Recement of inlay, onlay, custom fabricated/cast or prefabricated post and core and crown, Prefabricated stainless steel, stainless steel crown with resin window and resin crowns. Service includes local anesthesia, insertion with cementation and adjusting occlusion. Core buildup including pins Pin retention Indirectly fabricated (custom fabricated/cast) and prefabricated post and core Additional fabricated ( custom fabricated/cast) and prefabricated post Post removal Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture Coping Crown repair Protective restoration/sedative filling Endodontic Services Service includes all necessary radiographs or views needed for endodontic treatment. Teeth must be in occlusion, periodontally sound, needed for function and have good long term prognosis. Emergency services for pain do not require prior authorization. Service requires prior authorization and will not be considered for teeth that are not in occlusion or function and have poor long term prognosis. Endodontic service to include: Therapeutic pulpotomy for primary and permanent teeth Pulpal debridement for primary and permanent teeth Partial pulpotomy for apexogensis Pulpal therapy for anterior and posterior primary teeth Endodontic therapy and retreatment