UnitedHealthcare SignatureValueTM Benefit Interpretation Policy Manual DISCLAIMER General Statements: 

All benefits are specified in the Member's Evidence of Coverage, Schedule of Benefits and the Employer's Group Subscriber Agreement



All services rendered must be medically necessary as determined by the Member's provider



All services rendered must be referred and authorized by the Member's provider (unless specifically stated in the Evidence of Coverage and/or the Employer's Group Subscriber Agreement)



UnitedHealthcare abides by the Code of Federal Regulations for coverage decisions



UnitedHealthcare complies with all applicable state and federal laws and regulations (including benefit mandates) regarding coverage decisions

The benefit interpretations contained within this UnitedHealthcare SignatureValueTM Benefit Interpretation Policy Manual (this "Manual") are guidelines to be used by UnitedHealthcare in each individual State (UnitedHealthcare) and its contracting providers and practitioners to make coverage determinations for SignatureValueTM Members. Benefit interpretations for SignatureValueTM Members are made on a case-bycase basis using the guidelines in this Manual. The benefit interpretations in this Manual are subject to change based upon changes in state and federal laws and regulations, changes in scientific knowledge/technology and evolving practice patterns. Covered benefits are specified in the Member's Evidence of Coverage, Schedule of Benefits and/or Employer's Group Subscriber Agreement only. If there are any differences between the Member's Evidence of Coverage, Schedule of Benefits and/or Employer's Group Subscriber Agreement and this Manual, the Member's Evidence of Coverage, Schedule of Benefits and/or Employer's Group Subscriber Agreement shall govern. Nothing in this Manual is intended to be construed as an expansion of benefits beyond the benefits specified in the Member's Evidence of Coverage, Schedule of Benefits and/or Group Subscriber Agreement or as a basis for payment of any benefits under UnitedHealthcare.. Nothing in this Manual is intended to be construed as establishing any guidelines for the practice of medicine or a standard of care for the practice of medicine. UnitedHealthcare does not practice medicine and does not make medical decisions for UnitedHealthcare

SignatureValueTM Members. Medical decisions for UnitedHealthcare SignatureValueTM Members are made by the treating physician in conjunction with the member. The information contained within this Manual is strictly confidential and proprietary to UnitedHealthcare. The information is not to be copied in whole or part; nor is the information to be distributed without express written consent of UnitedHealthcare. The benefit interpretations contained within this Manual are based upon: (1) federal and/or state laws and regulations which may be applicable to UnitedHealthcare SignatureValueTM; and (2) research, studies and evidence from other sources (including, but not limited to, the Food and Drug Administration). Many of the benefit interpretations in this Manual require a determination of medical necessity to establish coverage. Medical necessity determinations must be made by trained and/or licensed professional medical personnel only. UnitedHealthcare SignatureValueTM Members have the right to appeal benefit decisions in accordance with the procedures specified in the Member's Evidence of Coverage and/or Employer's Group Subscriber Agreement. Any questions regarding appeals should be directed to the appeals department for the Member's UnitedHealthcare SignatureValueTM State of enrollment. Hayes Medical Technologies: A source of information that may be relied upon by UnitedHealthcare in determining whether a particular treatment is Experimental or Investigational, and therefore not a covered benefit under this plan, includes HAYES Medical Technology Reports. However, UnitedHealthcare shall only disclose the HAYES Medical Technology Directory Report for the specific procedure or condition requested. Milliman Care Guidelines A source of information that may be relied upon to assist trained and/or licensed professional medical personnel with utilization management and clinical decisions includes Milliman Care Guidelines ™. Milliman Care Guidelines ™ are available to the public upon request. However, UnitedHealthcare shall only disclose the criteria or guidelines for the specific procedures or conditions requested.

UnitedHealthcare SignatureValueTM Benefit Interpretation Manual

UnitedHealthcare of Oklahoma, Inc.

SignatureValue™ Benefit Interpretation Policy SUBJECT:

ABORTION

TITLE:

Therapeutic, Spontaneous or Elective Abortion

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 1/7/00, 11/3/00, 9/17/03, 10/20/05, 8/28/07, 9/25/08, 10/31/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: A-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

Freedom of Conscience Act (Effective date: November 1, 2008). SECTION 2. NEW LAW A new section of law to be codified in the Oklahoma Statutes as Section 1-728.1 of Title 63, unless there is created a duplication in numbering, reads as follows: As used in the Freedom of Conscience Act: 1. “Health care facility” means any public or private organization, corporation, authority, partnership, sole proprietorship, association, agency, network, joint venture, or other entity that is involved in providing health care services, including a hospital, clinic, medical center, ambulatory surgical center, private physician's office, pharmacy, nursing home, university hospital, medical school, nursing school, medical training facility, inpatient health care facility, or other place where health care services are provided; 2. “Human embryo” means a human organism that is derived by fertilization, parthenogenesis, cloning, or any other means from one or more human gametes or human diploid cells; 3. “In vitro human embryo” means a human embryo, whether cryopreserved or not, living outside of a woman's body; 4. “Participate in” means to perform, practice, engage in, assist in, recommend, counsel in favor of, make referrals for, prescribe, dispense, or administer drugs or devices or otherwise promote or encourage; and 5. “Person” means any individual, corporation, industry, firm, partnership, association, venture, trust, institution, federal, state or local governmental instrumentality, agency or body or any other legal entity however organized. SECTION 3. NEW LAW A new section of law to be codified in the Oklahoma Statutes as Section 1-728.2 of Title 63, unless there is created a duplication in numbering, reads as follows: An employer shall not discriminate against an employee or prospective employee by refusing to reasonably accommodate the religious observance or practice of the employee or prospective employee, unless the employer can demonstrate that the accommodation would pose an undue hardship on the program, enterprise, or business of the employer, in the following circumstances: 1. An abortion as defined in Section 1-730 of Title 63 of the Oklahoma Statutes. The provisions of this section shall not apply if the pregnant woman suffers from a physical disorder, physical injury, or physical illness which, as certified by a physician, causes the woman to be in

imminent danger of death unless an abortion is immediately performed or induced and there are no other competent personnel available to attend to the woman. As used in this act, the term “abortion” shall not include the prescription of contraceptives; 2. An experiment or medical procedure that destroys an in vitro human embryo or uses cells or tissue derived from the destruction of an in vitro human embryo; 3. An experiment or medical procedure on an in vitro human embryo that is not related to the beneficial treatment of the in vitro human embryo; 4. An experiment or medical procedure on a developing child in an artificial womb, at any stage of development, that is not related to the beneficial treatment of the developing child; 5. A procedure, including a transplant procedure, that uses fetal tissue or organs that come from a source other than a stillbirth or miscarriage; or 6. An act that intentionally causes or assists in causing the death of an individual by assisted suicide, euthanasia, or mercy killing. SECTION 4. NEW LAW A new section of law to be codified in the Oklahoma Statutes as Section 1-728.3 of Title 63, unless there is created a duplication in numbering, reads as follows: A. No health care facility is required to admit any patient or to allow the use of the health care facility for the purpose of performing any of the acts specified in Section 3 of this act. B. A physician, physician's assistant, registered nurse, practical nurse, pharmacist, or any employee thereof, or any other person who is an employee of, member of, or associated with the staff of a health care facility in which the performance of an activity specified in Section 3 of this act has been authorized, who in writing, refuses or states an intention to refuse to participate in the activity on moral or religious grounds shall not be required to participate in the activity and shall not be disciplined by the respective licensing board or authorized regulatory department for refusing or stating an intention to refuse to participate in the practice with respect to the activity. C. A physician, physician's assistant, registered nurse, practical nurse, pharmacist, or any employee thereof, or any other person who is an employee of, member of, or associated with the staff of a health care facility is immune from liability for any damage caused by the refusal of the person to participate in an activity specified in Section 3 of this act on moral or religious grounds. The complete text of ORS 743.556 can be accessed at http://webserver1.lsb.state.ok.us/200708bills/HB/SB1878_hflr.rtf B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Federal Employees Health Benefits (FEHB) EOC: Services, drugs and supplies related to abortions are excluded from coverage except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result or an act of rape or incest. 1.

Therapeutic abortions are covered when a physical disorder, physical illness or physical injury, including life-endangering physical condition caused by or arising from the pregnancy, would place a pregnant woman in danger of death unless an abortion is performed.

2. D.

a. Therapeutic abortions may be covered by either medical (i.e., mifepristone) or surgical means. Services for the care and treatment of spontaneous abortions (miscarriage)

NOT COVERED Note: Federal Employees Health Benefits (FEHB) EOC: Services, drugs and supplies related to abortions are excluded from coverage except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result or an act of rape or incest. 1. 2.

E.

DEFINITIONS 1. 2. 3. 4.

5. 6.

F.

Elective abortions (an abortion initiated by the member for reasons other than medical necessity) unless member has the benefit as stated in Section A and/or B. Non-medically necessary selective reductions unless member has the benefit as stated in Section A and/or B.

Elective Abortion: Termination of pregnancy initiated by the member for reasons other than medical necessity. Medical Means: For the purposes of this policy, "medical means" refers to an abortion induced by the administration of a medication or a combination of medications. Mifepristone (Mifeprex™, RU-486): A medication approved by the FDA on September 28, 2000 for the medical termination of an intrauterine pregnancy. Selective Reduction: The Academy of Assisted Reproductive Technology Professionals defines selective reduction as the removal of one or more fetuses, usually in order to reduce a pregnancy to a singleton or twin pregnancy. Spontaneous Abortion: An abortion occurring without having been induced (also known as miscarriage). Therapeutic Abortion: A situation in which a physical disorder, physical illness or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy, would place a pregnant woman in danger of death unless an abortion is performed.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

ALLERGIES

TITLE:

Allergy Testing and Injections

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 6/18/03, 12/15/04, 6/16/06, 8/17/06, 7/16/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: A-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

Members may have benefits for allergy serum (injectable allergen/antigen extract). Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the Customer Service Department to determine coverage eligibility.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Allergy antigens and serum are covered for the SignatureValueTM plan. 1.

Services and supplies for allergy testing and treatment a. Examples include, but are not limited to: 1) Allergy testing may include complete blood count (CBC) with differential (e.g., eosinophil count, IgE level, smear of nasal secretions). 2) When respiratory symptoms are present, allergy testing may also include a chest X-ray. 3) Additional testing, as indicated, includes but is not limited to: a) Skin testing b) Total gamma globulins

4) 5)

c) Sputum exam d) Paranasal sinus X-ray e) Provocative antigen testing Radioallergosorbent test (RAST) only if skin testing is unsuccessful and/or the member is unable to tolerate skin testing due to an already existing skin condition. Administration of allergy serum (whether or not the serum is a covered benefit)

Also see Physicians Services policy. D.

NOT COVERED 1. 2. 3. 4. 5. 6. 7. 8.

Allergy serum (injectable allergen/antigen extract) unless member has the benefit as stated as covered under Section B Routine radioallergosorbent test (RAST) Cytotoxicity testing/Bryan’s test Urine autoinjection Skin titration/Rinket method Provocative and neutralizing testing (subcutaneous) for food allergies Sublingual provocative test Serum allergy/histamine release tests

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

AMBULANCE

TITLE:

Ambulance Transportation

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 6/20/02, 6/18/03, 11/18/04, 7/21/06, 8/17/06, 8/28/07, 9/25/08, 9/1/09, 10/21/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: A-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A. FEDERAL/STATE MANDATED REGULATIONS 1.

2.

Oklahoma Administrative Code 365:40-5-21 - Supplemental Health Care Services Supplemental health care services of a SignatureValue™ may include the following: ……… (8) Ambulance services, unless medically necessary …….. Title 36 Oklahoma Statutes §6907 (L), (M), (N), (O), and (P): L. Decisions by a health maintenance organization to authorize or deny coverage for an emergency service shall be based on the patient presenting symptoms arising from any injury, illness, or condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of medical attention to result in serious: 1. Jeopardy to the health of the patient; 2. Impairment of bodily function; or 3. Dysfunction of any bodily organ or part. M. Health maintenance organizations shall not deny an otherwise covered emergency service based solely upon lack of notification to the SignatureValue™. N. Health maintenance organizations shall compensate a provider for patient screening, evaluation, and examination services that are reasonably calculated to assist the provider in determining whether the condition of the patient requires emergency service. If the provider determines that the patient does not require emergency service, coverage for services rendered subsequent to that determination shall be governed by the SignatureValue™contract. O. If within a period of thirty (30) minutes after receiving a request from a hospital emergency department for a specialty consultation, a health maintenance organization fails to identify an appropriate specialist who is available and willing to assume the care of the enrollee, the emergency department may arrange for emergency services by an appropriate specialist that are medically necessary to attain stabilization of an emergency medical condition, and the SignatureValue™ shall not deny coverage for the services due to lack of prior authorization. P. The reimbursement policies and patient transfer requirements of a health maintenance organization shall not, directly or indirectly, require a hospital emergency department or provider to violate the federal Emergency Medical Treatment and Active Labor Act. If a member of an SignatureValue™ is transferred from a hospital emergency department facility to another medical

facility, the SignatureValue™ shall reimburse the transferring facility and provider for services provided to attain stabilization of the emergency medical condition of the member in accordance with the federal Emergency Medical Treatment and Active Labor Act. B. STATE MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

D.

Ambulance transportation by ground or air to the nearest appropriate facility when medically necessary (see Emergency and Urgent Services and Medical Necessity policies) a. Ground ambulance transportation using a basic life support or an advanced life support ambulance for the following transfers when medical necessity for ground ambulance transport is met: 1) Inter-hospital or skilled nursing facility transfers (skilled care only) 2) Hospital and renal dialysis facility 3) Skilled nursing facility and dialysis facility (skilled care only) 4) Skilled nursing facility and radiation therapy (skilled care only) 5) Skilled nursing facility (SNF) and hospital and member’s home b. Air ambulance transportation is a covered benefit only when 1) The member’s destination is an acute care hospital 2) The member’s condition is such that the ground ambulance would endanger the member’s life or health 3) Inaccessibility to ground ambulance transport or extended length of time required to transport the member via ground transport could endanger the member 4) Weather or traffic conditions make ground transport impractical, impossible or overly time consuming c. Out-of-area ambulance service (ground or air) in conjunction with out-of-area care as listed above Ambulance transportation for the member that is requested by public entities (e.g., police, school, and social services) is covered if one of the following criteria is met: a. Reasonably complete and accurate documentation by the ambulance supplier demonstrates that the transportation furnished was medically necessary b. UnitedHealthcare independently determines that the transportation was medically necessary

NOT COVERED 1. 2.

Any ambulance service to provide member transport for routine care when transport by other means would not endanger the member’s health except as indicated in Section C. Any ambulance service when the member is unable to locate another form of transport and the

3. 4. 5. 6. 7. 8.

member’s health would not be compromised Any ambulance service that serves only as a convenience for either the member or his/her family Ambulance service (ground or air) to the coroner’s office or mortuary Personal transportation costs such as gasoline costs for a private vehicle or taxi fare Inter-hospital or skilled nursing facility transportation due to a patient request or convenience Any ambulance service from one contracting facility to another contracting facility unless the transfer is necessary to deliver medical services when a higher level of care is required For members out-of-country, transportation back to the United States when there is a foreign facility that is capable of managing the member’s condition

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

ARTIFICIAL HEARTS AND RELATED DEVICES

TITLE:

Ventricular Assist Devices (VADs)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/22/99

Effective Date: 1/1/00

Review Date: 12/5/02, 12/18/03, 3/17/04, 10/6/04, 8/17/06, 7/16/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: A-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS

IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section. 1.

D.

NOT COVERED 1. 2.

E.

Ventricular Assist Devices (VADs): a. As a bridge to transplant b. To support circulation of blood following open-heart surgery (post-cardiotomy)

Artificial hearts VADs when used as destination therapy

DEFINITIONS 1.

2.

Ventricular assist device (VAD): A mechanical pump that helps a heart that is too weak to pump blood through the body. It is sometimes referred to as “a bridge to transplant” since it can help a patient survive until a heart transplant can be performed. Destination Therapy: The VAD is placed with the expectation that the patient will likely require permanent cardiac mechanical support.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

TITLE:

Attention Deficit Hyperactivity Disorder (ADHD)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 6/7/00, 6/20/02, 06/18/03, 10/20/05, 8/28/07, 2/14/08, 2/18/09, 2/17/10, 2/16/11, 02/23/12, 02/28/13

Policy Number: A-006

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

This policy applies to members with diagnosed or suspected Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) or other related disorders. A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2. 3.

Assessment and coordination of care of the above listed disorders by the member's pediatrician or PCP (e.g., history, physical and management of medications) Referral for consultation and evaluation of individuals with suspected complex developmental and/or behavioral problems for confirmation of diagnosis Treatment of any underlying coexistent medical condition (e.g., Tourette's Syndrome, seizure disorder), based on medical necessity

Also see Pervasive Developmental Disorder, Developmental Delay, Mental Health: Outpatient, and Rehabilitation: Medical -Physical, Occupational and Speech Therapy policies

D.

NOT COVERED 1.

2. 3.

4.

Specific therapies for the treatment of suspected complex developmental and/or behavioral problems, including speech therapy. Individuals should be referred to appropriate community resources (e.g., school district, regional center) for these services. Assessment and therapy for learning disabilities (e.g., reading, mathematics and/or written expression disorders), except for underlying coexistent medical conditions Other non-medical therapies or treatment programs. Examples include, but are not limited to: a. Non-crisis mental health counseling b. Behavior modification program c. Vocational and community living skills d. Learning or reading disorders e. Psychoanalysis f. Biofeedback g. Residential living programs h. Non-crisis family counseling i. Learning consultants, non-licensed health professionals and licensed counselors j. Music integration therapy Prescription drugs, unless member has supplemental prescription benefit

Also see Pervasive Developmental Disorder, Developmental Delay, Mental Health: Outpatient, and Rehabilitation: Medical -Physical, Occupational and Speech Therapy policies E.

DEFINITIONS 1. 2.

F.

Attention Deficit Hyperactivity Disorder (ADHD): ADHD is a neurobiological disability. It is characterized by inattention, impulsive behavior and sometimes hyperactivity inappropriate for age. Learning Disability: A condition that exists when there is a meaningful difference between a child's current academic level of function and the level that would be expected for a child of that age and intelligence level.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

BIOFEEDBACK

TITLE:

Biofeedback

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/2000

Review Date: 7/12/01, 6/20/02, 6/18/03, 8/31/04, 5/19/05, 7/14/06, 8/28/07, 5/22/08, 4/15/09, 4/21/10, 4/26/12, 04/25/13

Policy Number: B-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Biofeedback for bladder rehabilitation as part of an authorized treatment plan. Examples include, but are not limited to: a. Biofeedback for the treatment of stress and/or urge urinary incontinence for cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training 1) A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength. b. Biofeedback for fecal incontinence or constipation in patients with organic neuromuscular impairment c. Biofeedback for children who have dysfunctional voiding syndrome with urinary retention

Also see Incontinence Control (Adult) policy and Medical Management Guidelines: Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence (click Internal, Provider Portal or Member).

D.

NOT COVERED 1.

E.

DEFINITIONS 1.

2.

F.

Biofeedback for conditions other than those listed above in Sections B and/or C including use of home biofeedback therapy

Biofeedback: A training program designed to develop the member’s ability to control their autonomic (involuntary) nervous system. After learning the techniques, the member may be able to control their heart rate and blood pressure or relax certain muscles. Intrinsic Sphincter Deficiency (ISD): A cause of stress urinary incontinence in which the urethral sphincter is unable to contract and generate sufficient resistance in the bladder, especially during stress testing maneuvers.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

BLOOD

TITLE:

Blood and Blood Products

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 5/6/03, 9/17/03, 12/5/05, 8/28/07, 9/25/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: B-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma HMO Licensure Rules, 310: 655-5-1: Comprehensive services shall include administration of whole blood and blood plasma as part of inpatient hospital services. Additionally, comprehensive services shall include outpatient services, including diagnostic services, treatment services and X-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at a hospital.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Use and administration of blood and blood components, including but not necessarily limited to: a. Cryoprecipitate b. Platelets c. Fibrinogen d. Plasma e. Gamma globulin f. Albumin

2. 3. 4. 5.

6. D.

NOT COVERED 1. 2.

E.

Platelet derived wound healing formulas, such as Procuren or other similar blood products used in the repair of chronic, nonhealing, cutaneous ulcers or wounds Blood charges associated with non-authorized or non-covered procedures

DEFINITIONS 1.

2. 3.

4.

5.

F.

Blood provided through a blood bank on either an inpatient or outpatient basis Blood clotting factors for members diagnosed with hemophilia and the equipment necessary for the administration of such factors (e.g., Factor VIII) Synthetic blood products, only when determined to be medically necessary by a UnitedHealthcare Medical Director or his/her designee Autologous (self-donated) and donor-directed (donor-designated) blood processing costs only for a scheduled procedure, including storage fees charged as a result of the physician and/or provider cancellations, which are beyond the member’s control (Note: See Section B for additional benefit information.) Cost of blood collected but not used if the physician authorized the need

Allogeneic Blood Products (Blood Bank): Whole blood, packed cells, blood components, platelets, and blood factor replacements such as Factor I (Fibrinogen), Factor VIII (antihemophilia) and Factor IX (Christmas Disease). Autologous Blood: Self-donated blood that is collected and pre-deposited for the member’s own use. Blood Derivatives: Blood derivatives are used for immunization, vaccination or prophylaxis. Derivatives include immune globulin, gamma globulin, Hepatitis B immune globulin, Tetanus immune globulin, immune globulin (RHIG) and Rho (D) immune globulin (RhoGam). Donor Directed (Designated) Blood: Blood donated from a family member or other acquaintance of the member to be used specifically for the member as an alternative to self-donated (autologous) blood or blood from the volunteer blood supply. Synthetic Blood Products: Examples include Plasma Protein FXN (Plasmanate), Plasmatein (Plasma Plex), Ibumin (human), and Dextran.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CARDIAC PACEMAKERS AND DEFIBRILLATORS

TITLE:

Cardiac Pacemakers and Defibrillators

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 3/1/01, 5/6/03, 1/14/04, 3/17/04, 10/6/04, 2/2/05, 11/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: C-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2.

Cardiac pacemakers (single-chamber or dual chamber), when medical criteria are met Cardiac pacemaker monitoring a. Self-contained pacemaker monitors when prescribed by the treating physician 1) Digital electronic pacemaker monitor provides the patient with an instantaneous digital readout of his pacemaker pulse rate. Use of this device does not involve professional services until there has been a change of five pulses (or more) per minute above or below the initial rate of the pacemaker; when such change occurs, the patient contacts his physician. 2) Audible/Visible signal pacemaker monitor produces an audible and visible signal which indicates the pacemaker rate. Use of this device does not involve professional services until a change occurs in these signals; at such time, the patient contacts his physician. Note: The design of the self-contained pacemaker monitor makes it possible for the patient to monitor his pacemaker periodically and minimizes the need for regular visits to the

3. 4.

D.

NOT COVERED 1.

E.

Cardiac pacemakers, cardiac pacemaker monitoring or automatic defibrillators when criteria are not met.

DEFINITIONS 1.

F.

outpatient department of the provider. b. Transtelephonic cardiac pacemaker monitoring 1) Limited to lithium battery powered pacemakers 2) Transtelephonic cardiac monitoring may be done by: a) Member’s physician b) Outside entity – requires an annually renewed physician’s prescription and may include: (1) Commercial monitoring service (2) Hospital outpatient department (3) Pacemaker clinic 3) Frequency of monitoring a) Responsibility of member’s physician to determine frequency b) Frequency may vary over time and require modifications 4) Transtelephonic cardiac monitoring must consist of the following: a) Minimum 30 second readable strip of the pacemaker in the free running mode b) Unless contraindicated, a minimum 30 second readable strip of the pacemaker in the magnetic mode c) Minimum 30 seconds of readable ECG/EKG strip Implantable automatic defibrillators when medical criteria are met. Automatic external defibrillators when member meets either (1) both criteria a and b or (2) criterion c: 4. Criteria for implantable automatic defibrillators are met. b. Implantation surgery is contraindicated. c. A previously implanted defibrillator now requires explantation.

Implantable Automatic Defibrillator: An electronic device designed to detect and treat lifethreatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CAREGIVERS SOLUTION

TITLE:

A Solution for Caregivers – Core Benefit

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/5/04

Effective Date: 5/5/04

Review Date: 5/4/06, 8/28/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: C-009

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

None

STATE MARKET PLAN ENHANCEMENTS 1.

Depending on the member’s employer group plan, some members may have coverage for A Solution for Caregivers benefit. Refer to the member’s EOC/SOB or contact the Member Services Department to determine coverage eligibility. If member has the benefit coverage, refer to the A Solution For Caregivers Rider policy.

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless member has the caregivers solutions benefit as stated in Section B.

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CAREGIVERS SOLUTIONS

TITLE:

A Solution for Caregivers - Rider

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/5/04

Effective Date: 5/5/04

Review Date: 5/4/06, 8/28/07, 11/15/10

Policy Number: C-009-R

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern. IMPORTANT NOTE – READ BEFORE USING THIS BENEFIT INTEPRETATION POLICY Depending on the member’s employer group plan, some members may have coverage for A Solution for Caregivers benefit. Refer to the member’s EOC/SOB or contact the Member Services Department to determine coverage eligibility before using this policy

A. FEDERAL/STATE MANDATED REGULATIONS 1.

None

B. STATE MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Telephonic Care Resource Center (CRC) services a. Coaching and support 1) Unlimited toll-free access to geriatric experts. 2) Unlimited coaching on dealing with family issues and stresses of caregiving. b. Personalized research and identification of services 1) Unlimited access to personalized research on elder care topics by geriatric specialists. 2) Research on community program that may fit a family’s caregiving needs. 3) Identification and screening of local support services such as meal delivery, transportation, housekeeping. c. Elder Law Information and Referral Services 1) Access to contracted nationwide network of Elder Law attorneys. a) Elder Law information and referral for up to 2 hours per eligibility year of free consultation on elder law issues on up to 4 topics per eligibility year. 2) Cost-free preparation of up to four each of Simple Wills or Living Wills for the

2.

member, spouse, parents, or adult family member under the care of the member per eligibility year. 3) Consultation and then preparation (if needed) of up to four of the following documents per eligibility year for a $35 per document fee paid to the contracted attorney: -Durable Power of Attorney -Health Care Durable Power of Attorney -Financial Durable Power of Attorney -Health Care Directive 4) Document review and preparation, including Wills and Durable Powers of Attorney, can be used for the member, spouse, parent, spouse’s parents, or other adult family cared for by the member. Geriatric Care Manager (GCM) services through contracted network for up to 6 hours per eligibility year that can be used for the specific needs of the caregiver. Typical uses include: a. At-home assessment to review the current situation and plan for future care. b. Detailed report to help the caregiver understand the current care needs and help them select care services. c. Extensive review of local support services, including suggested next steps for the caregiver and care recipient to consider. d. Assistance in setting up and coordinating services, from community-based private and public agencies, that may meet the care recipient’s needs. e. Review of alternative living facilities, such as assisted living or skilled nursing. f. Assistance with the identification of home or support accommodations needed upon hospital discharge. g. Research and screening local home care service providers.

D. NOT COVERED 1. 2. 3. 4.

5.

6.

7. 8.

Any community, private or government-funded programs chosen by the member as a result of receiving personalized research. Any public or private care services chosen by the member as a result of receiving identification and screening services. Elder Law Referral services requested by the member above and beyond the two free hours maximum coverage limit. Documents reviewed or created above and beyond those defined as covered as Elder Law Referral Services. A Simple Will is determined by the contracted attorney’s exercise of his/her professional opinion. Medical services obtained at the recommendation of Geriatric Care Managers or the Care Resource Center except those covered services described in the Schedule of Benefits and the Evidence of Coverage. Geriatric Care Manager services beyond the 6 hours maximum eligibility year coverage limit has been reached. If member chooses to continue Geriatric Care Manager services beyond the six covered hours per eligibility year, they may do so at their sole expense. Alternative living facilities, custodial care, domiciliary care, or other facility charges. Caregiver services, including Geriatric Care Manager services that are not arranged for or provided by the Care Resource Center.

E. DEFINITIONS 1. 2.

Care Resource Center: A centralized information and research service managed by experienced geriatric specialists. Geriatric Care Manager: A professional who specializes in elder and aging care and has training

in gerontology, social work, nursing, or counseling. F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CHANGE IN MEMBERSHIP STATUS

TITLE:

Change in Membership Status While Hospitalized

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 1/7/00

Effective Date: 1/1/00

Review Date: 6/23/04, 5/4/06, 5/22/08, 4/15/09, 4/21/10, 4/19/11, 4/26/12, 04/25/13

Policy Number: C-007

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

Oklahoma Statutes Title 36 §4509.1 - Replacement of Contract; Liability A. This section applies to determination of the liability of a carrier pursuant to a group or blanket accident or health insurance plan in those instances in which the contract of one carrier replaces a plan of similar benefits of another carrier. As used in this section, "carrier" means an insurer or other entity subject to the provisions of Title 36 of the Oklahoma Statutes, and includes but is not limited to a not-for-profit hospital service and medical indemnity corporation, a fraternal benefit society, a health maintenance organization and a multiple employer welfare arrangement. B. The prior carrier shall be liable only to the extent of its accrued liabilities and extensions of benefits. The position of the prior carrier shall be the same whether the group policyholder or other entity responsible for making payments or submitting subscription charges to the carrier secures replacement coverage from a new carrier, self-insures, or foregoes the provision of coverage. C. Each person who was covered by the plan of the prior carrier shall be covered by the plan of benefits of the succeeding carrier conditioned only upon the payment of the premium. D. The succeeding carrier, in applying any deductibles or waiting periods in its plan, including but not limited to waiting periods for preexisting conditions, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits and shall not impose any additional waiting periods for coverage for any person who was covered by the plan of the prior carrier. In the case of deductible provisions, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible provisions of the prior plan during the ninety (90) days preceding the effective date of the succeeding plan but only to the extent these expenses are recognized under the terms of the plan of the succeeding carrier and are subject to similar deductible provision.

E. If a determination of the benefits of the prior plan is required and requested by the succeeding carrier, upon receiving such request, the prior carrier shall furnish a statement of the benefits available or pertinent information sufficient either to permit verification of the benefits available under the prior plan or to permit the determination of the benefits by the succeeding carrier. For the purposes of this subsection, benefits of the prior plan shall be determined in accordance with all of the definitions, conditions, and covered expense provisions of the prior plan and shall not be subject to the definitions, conditions, and covered expense provisions of the succeeding plan. The benefit determination shall be made as if coverage had not been replaced by the succeeding carrier.

2.

F. Nothing in this section shall prevent an individual from electing not to be covered under the plan of benefits of the succeeding carrier. Oklahoma Statutes Title 36 §4509.2 - Liability of Succeeding Carrier A. When an insured individual or a dependent who was covered by group insurance pursuant to the provisions of the Health Insurance Portability and Accountability Act of 1996, 29 U.S.C.A., Section 1181 et seq., gains employment with an employer who provides for health insurance through a group plan, the succeeding group carrier shall accept the insured individual and dependents of the insured individual who were covered under the prior coverage and shall not apply limitations or exclusions based on preexisting conditions or apply waiting-period requirements for the insured individual or the dependents of the insured individual beyond the time when any surviving exclusion or waiting period with the prior carrier would have been fulfilled. The insured individual and any dependents of such individual must apply for the new coverage within sixty-three (63) days following the date of termination of prior creditable coverage. B. When an insured individual or dependent who was covered by individual insurance pursuant to the provisions of the Health Insurance Portability and Accountability Act of 1996, 29 U.S.C.A., Section 1181 et seq., gains employment with an employer who provides for health insurance through a group plan, the succeeding group carrier shall accept the insured individual and dependents of the insured individual who were covered under the prior coverage and shall not apply limitations or exclusions based on preexisting conditions or apply waiting-period requirements for the insured individual or the dependents of the insured individual beyond the time when any surviving exclusion or waiting period with the prior carrier would have been fulfilled. The insured individual and any dependents of such individual must apply for the new coverage within sixty-three (63) days following the date of termination of prior creditable coverage. C. Insurance carriers receiving an application for individual insurance may underwrite the risk or decline coverage based on the underwriting guidelines of the insurance carrier. Upon denial of coverage, insurance carriers shall advise the applicant of the existence of, and how to apply for coverage under, the Health Insurance High Risk Pool. D. When there is a lapse in the coverage of the insured individual or a dependent of the insured individual provided for by subsections A, B, and C of this section for any reason other than a probationary period or similar waiting period imposed pursuant to personnel policies of an employer, the provisions of subsections A, B, and C of this section shall not apply to the person whose coverage lapsed. E. When an individual employee who was covered under a group health insurance plan terminates employment with an employer and gains employment with another employer who provides for

health insurance through a group plan, the carrier of the succeeding employer shall not apply preexisting conditions limitations or exclusions of preexisting conditions or apply waiting-period requirements for the individual employee or his dependents covered under the group plan of the previous employer beyond the time when any surviving exclusion or waiting period with the prior carrier would have been fulfilled, provided the individual employee applies for the new coverage within thirty-one (31) days following the date of eligibility for participation in the plan in accordance with the employment or personnel policies of the employer of such participation.

3.

F. When there is a lapse in the coverage of the individual employee provided for by subsection E of this section for any reason other than a probationary period or similar waiting period imposed by the employment or personnel policies of the employer, the provisions of subsection E of this section shall not apply. OAC - 365:40-5-72. Continuation of benefits (a) If group or individual contracts are terminated by the HMO, provision shall be made for continuation of benefits to enrollees who, on the date of termination, are confined in an inpatient facility until their discharge or expiration of benefits according to the group or individual contract, and provision shall be made for pregnant enrollees through delivery and discharge. An HMO is not required to continue further benefits for an enrollee or group terminated for cause.

Health Plan Note:

B.

In accordance with UnitedHealthcare’s Evidence of Coverage, a Member’s new carrier becomes responsible for all healthcare services as of the Member’s first date of eligibility with the plan. The Medical Group/IPA and Capitated Hospital become responsible to authorize and direct a Member’s care and pay claims as of the Member’s first date of eligibility with the new health plan, regardless of the Member’s inpatient status.

•

For Federal members: If a Federal member is in the hospital when enrollment begins, the former carrier will pay for the hospital stay until discharge, or benefit expiration, or the 92nd day on UnitedHealthcare, whichever comes first.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

•

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Refer to Sections A for market specific coverage relating to a change in membership status while hospitalized.

D.

NOT COVERED

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CHEMOTHERAPY

TITLE:

Chemotherapy

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 5/6/03, 3/24/05, 2/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: C-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

Oklahoma Statute § 63–1–2605: Any group or non-group health maintenance contract which provides coverage for prescription drugs shall also provide coverage of off-label uses of prescription drugs used in the treatment of cancer or the study of oncology.

STATE MARKET PLAN ENHANCEMENTS 1.

None

Note: Co-payments may be applicable for injectable chemotherapy medications depending on the member's specific plan code. Refer to the benefit matrix or contact the Customer Service Department for specific co-payment information. C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2.

Chemotherapy, immunotherapy, and hormonal agents, when medically necessary and used accordingly for FDA approved indications or as a part of a cancer treatment regimen In the case of FDA approved drugs used in an anticancer chemotherapeutic regimen, off label uses are covered for a medically necessary indication and are subject to the following criteria: a. Off label use must be medically accepted with support for efficacy in one of the following:

1) 2)

3. 4. 5.

American Hospital Formulary Service Drug Information Two articles from major peer-reviewed medical journals showing scientific evidence supporting the off label use for the targeted condition 3) United States Pharmacopoeia Dispensing Information, Volume 1 b. The drug and its intended use must not be on the list of exclusions under "drugs not covered" in the UnitedHealthcare Formulary c. All possible formulary alternatives have been tried without clinical success or are contraindicated for the particular member's targeted condition Injectable drugs are covered under the medical benefit Oral drugs (e.g., oral anti-nausea drugs and oral chemotherapy drugs) if the member has a supplemental prescription benefit Examples of covered benefits include, but are not limited to: a. Inpatient or outpatient oncology services b. Follow-up appointments with member to monitor chemotherapy treatment c. Other related services administered on a day other than the treatment day d. Outpatient chemotherapy labs taken on the same day as chemotherapy treatment

Also refer to Cancer Clinical Trials, Medications(Oral, Infusion, Injectable) and Off-label Drug Use, and Experimental and/or Investigational Procedures policies D.

NOT COVERED 1. 2. 3. 4. 5. 6.

E.

DEFINITIONS 1. 2.

3.

F.

Medication given by injection in instances where standard medical practice indicates that the medication given by mouth is an effective and accepted or preferred method of treatment Administration of medications that exceed the frequency and duration of injections indicated by standard medical practice Complementary and alternative medicine (Refer to the Complementary and Alternative Medicine policy) Transportation and lodging costs Off-label use of a medication not meeting the criteria in Section C. Oral drugs (e.g., oral anti-nausea drugs and oral chemotherapy drugs) except when member has a supplemental prescription benefit

Cancer Treatment Regimen: Includes drugs used to treat toxicities or side effects of cancer treatment when the drug is given incident to a chemotherapy treatment. FDA Approved Drug: A drug that has received final marketing approval by the Food & Drug Administration (FDA) and, as a part of its labeling, contains its recommended uses and dosages as well as adverse reactions and recommended precautions in using it. Off Label Use of a Drug : A use that is not included as an indication on the drug's label as supported by the FDA.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

CLINICAL TRIALS

TITLE:

Routine Costs in Clinical Trials

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 9/17/03

Effective Date: 9/17/03

Review Date: 12/5/05, 11/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: C -004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A. FEDERAL/STATE MANDATED REGULATIONS 1.

None

B. MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless covered under Section A..

D. NOT COVERED 1.

Clinical trials are not covered unless stated in Section A.

E. DEFINITIONS 1.

Clinical Trial (as defined by NIH): A type of research study that tests how well new medical treatments or other interventions work in people. Such studies test new methods of screening, prevention, diagnosis, or treatment of a disease. The study may be carried out in a clinic or other medical facility. Also called a clinical study. Clinical trials are usually classified into one of three phases: a. Phase I trials: These first studies in people evaluate how a new drug should be given (by mouth, injected into the blood, or injected into the muscle), how often, and what dose is safe. A Phase I trial usually enrolls only a small number of patients, sometimes as few as a dozen. b. Phase II trials: A Phase II trial continues to test the safety of the drug, and begins to evaluate how well the new drug works. Phase II studies usually focus on a particular type of cancer

c.

Phase III trials: These studies test a new drug, a new combination of drugs, or a new surgical procedure in comparison to the current standard. A participant will usually be assigned to the standard group or the new group at random (called randomization). Phase III trials often enroll large numbers of people and may be conducted at many doctors' offices, clinics, and cancer centers nationwide.

E. REFERENCES 1.

National Institutes of Health (NIH, 2001). Available at http://www.nci.nih.gov/clinicaltrials/understanding/what-is-a-clinical-trial

SignatureValue™ Benefit Interpretation Policy SUBJECT:

COMPLEMENTARY AND ALTERNATIVE MEDICINE

TITLE:

Complementary and Alternative Medicine

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 9/1/00

Effective Date: 9/1/00

Review Date: 6/20/02, 9/19/02, 6/18/03, 3/24/05, 2/6/07, 2/14/08, 2/18/09, 2/17/10, 2/16/11, 02/23/12, 02/28/13

Policy Number: C-008

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Statutes Title 36 Section 6933 Chiropractic Services: With respect to chiropractic services, such covered services shall be provided on a referral basis within the network at the request of a member who has a condition of an orthopedic or neurological nature if: a. A referral is necessitated in the judgment of the primary care physician and b. Treatment for the condition falls within the licensed scope of practice of a chiropractic physician.

Some members may have chiropractic, acupuncture or other alternative care benefits. Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the Customer Service Department to determine coverage eligibility.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. D.

None unless the member has the benefit as stated in Section A or B

NOT COVERED 1.

Complementary and alternative therapies are not covered unless the member has the benefit as stated in Section A or B a. Examples of non-covered services include, but are not limited to: 1) Acupuncture/Acupressure

2) 3) 4)

E.

21)

Hypnosis

DEFINITIONS 1.

2.

F.

5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20)

Chiropractic services Massage therapy Oriental massage, Swedish massage (see Rehabilitation: Medical - Physical, Occupational and Speech Therapy policy) Energy therapies Meditation Herbal therapy Yoga Tai Chi Spiritual healing Community based approaches (e.g., Alcoholics Anonymous, Overeaters Anonymous) Medical intuition Pilate's method Light and color therapy Colonics Applied kinesiology Neural therapy Therapeutic touch Electromagnetic fields for medical purposes (e.g., magnetic chairs) Reiki

Complementary and alternative medicine (as defined by NCCAM): A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine. (e.g., using aroma therapy to help lessen a patient's discomfort following surgery). Alternative medicine is used in place of conventional medicine (e.g., using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor). Conventional medicine (as defined by NCCAM): Medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Other terms for conventional medicine include allopathy; Western, mainstream, orthodox, and regular medicine; and biomedicine. Some conventional medical practitioners are also practitioners of complementary and alternative medicine.

REFERENCES 1.

NIH National Center for Complementary and Alternative Medicine (NCCAM), NCCAM Publication No. D156, May 2002

SignatureValue™ Benefit Interpretation Policy SUBJECT:

COURT/ATTORNEY OR AGENCY REQUESTED SERVICES

TITLE:

Court/Attorney or Agency Requested Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 12/5/02, 12/18/03, 2/16/06, 2/14/08, 2/18/09, 2/17/10, 2/16/11, 02/23/12, 02/28/13

Policy Number: C-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/MARKET MANDATED REGULATIONS 1.

B.

MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

Court/attorney or agency requested services and testing only when they are medically reasonable and necessary (see Medical Necessity and Periodic Health Examinations/Preventive Services policies) Emergency services or urgently needed services (see Emergency and Urgent Services policy)

Note: For coverage of services required for injuries or illnesses while under arrest, detained, imprisoned, or incarcerated, see the Services While Confined policy D.

NOT COVERED 1.

Examples include, but are not limited to: a. Evaluation and therapy orders by a court for accused sex offenders

b. c. d. e.

Attorney requesting a medical consultation in a civil liability case Paternity testing Developmental testing Substance abuse testing

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DENTAL CARE AND ORAL SURGERY

TITLE:

Dental Care and Oral Surgery

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 1/5/01, 12/6/01, 12/5/02, 12/18/03, 2/2/05, 12/7/06, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: D-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

2.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Department of Insurance Title 36, Section 6060.6: Provides coverage for anesthesia expenses, hospital expenses, ambulatory surgical center expenses, and anesthesia practitioner expenses associated with any inpatient or outpatient hospital dental procedure for the severely disabled, or minors 8 years of age or under, who have a medical or emotional condition that requires hospitalization or general anesthesia for dental care. Oklahoma Administrative Code 365:40-5-20 (12): Inpatient and outpatient care for treatment of the birth defect known as cleft lip or cleft palate or both including medically necessary oral surgery, orthodontics and otologic, audiological and speech/language treatment.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Oral surgery or dental services, rendered by a physician or dental professional, for treatment of primary medical conditions. Examples include, but are not limited to: a. Setting of the jaw or facial bones (includes wiring of teeth when performed in connection with the reduction of the jaw fracture) b. Reconstruction of the jaw when medically necessary (e.g., radical neck or removal of mandibular bone for cancer or tumor)

c. d.

e. f. g. h.

i. j. k. l. m.

Reconstruction of a ridge that is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes) Insertion of metallic implants if the implants are used to assist in or enhance the retention of a dental prosthetic as a result of a covered service under the member’s medical plan. (Note: Crowns, dentures, and other dental prostheses are not covered even if supported by the implants.) Oral or dental examinations performed on an inpatient or outpatient basis as part of a comprehensive workup prior to transplantation surgery Extraction of teeth if medically necessary for members undergoing transplant procedures Extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease Emergency treatment for the stabilization of acute accidental injuries to sound natural teeth, jawbone or surrounding tissues immediately following injury or as soon as the member is medically stable Biopsy of gums or soft palate Treatment of maxillofacial cysts, including extraction and biopsy Facilities and anesthesia charges in a contracted facility when a dental procedure cannot be performed in a dental office due to an underlying medical condition and/or clinical status Fluoride trays and/or bite guards used to protect teeth from caries and possible infection during radiation therapy Denture as part of the prosthesis when the denture or a portion of denture is an integral part (built-in) of an obturator which fills an opening in the palate)

Also see Surgery: Orthognathic, Surgery: Cosmetic, Reconstructive or Plastic and Treatment of Temporomandibular Joint (TMJ) Disorders policies D.

NOT COVERED 1.

Services related to routine dental care (see Section E), unless member has supplemental dental coverage 2. Dental care beyond the emergency treatment required to stabilize acute accidental injuries to sound natural teeth, jawbone or surrounding tissues 3. Cosmetic surgery or treatment provided solely to improve the member's appearance and not intended to improve the physical functioning of a malformed body part(s) (see Surgery: Cosmetic, Reconstructive or Plastic and Medical Necessity policies) 4. Inpatient or outpatient hospitalization due to age and/or behavioral problems when no medical problem exists that would require the continuous monitoring by an anesthesiologist 5. Extraction of an impacted tooth, except as addressed above 6. Reconstruction of the jawbone or supporting tissues to provide a better fit for dentures or other mouth prostheses or reconstruction of the jawbone following services that were originally dental in nature 7. Removal of teeth for the main purpose of fitting for dentures 8. Alveoplasty when performed in connection with an excluded service, such as preparation of the mouth for dentures 9. Application of dental/orthodontic devices/appliances, whether or not it accompanies oral and/or orthognathic surgery, except as addressed in the Treatment of Temporomandibular Joint (TMJ) Disorders policy (see Treatment of TMJ Disorders policy) 10. Dental/orthodontic or surgical correction of malocclusion or any abnormality resulting from

11. 12. 13. 14.

E.

DEFINITIONS 1. 2.

3. 4.

5. 6.

7.

F.

malocclusion under either of the following circumstances: a. The malocclusion can be corrected by other measures (e.g., use of mouth appliances such as retainers, braces or splints) b. The malocclusion is not accompanied by any demonstrable functional impairments Physician services provided in connection with non-covered dental services Dental implants Bone grafts for preparation of dental implants Crowns, dentures, and other dental prosthesis are not covered unless specifically provided for under Section C

Alveoplasty: Conservative contouring of the alveolar process in preparation for immediate or future denture construction. Cosmetic Surgery: Cosmetic or reconstructive surgery used to alter and improve the member's physical appearance or to improve the member's self-esteem and which provides no improvement to a functional impairment. Dental/Orthodontic Devices/Appliances: Any device used to influence growth or the position of teeth and jaws. (e.g., braces, retainers, night guards, oral splints) Dental Implant: A device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement; endosteal (endosseous); eposteal (subperiosteal); transosteal (transosseous). (American Dental Association Glossary) Dental Prosthesis: An artificial device that replaces one or more missing teeth. (American Dental Association Glossary) Routine Dental Care: Services in connection with care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. Services include those for crowns, root canals, replacement of teeth, complete dentures, gold inlays, fillings, and other dental services specific to the treatment of the teeth. Skeletal Facial Deformities: These deformities include abnormalities of jaw-to-jaw size and shape and excessive (hyperplasia) or deficient (hypoplasia) bone-to-bone or bone-to-soft tissue relationships. Such deformities can cause facial pain, premature loss of teeth, chewing problems, speech defects, temporomandibular joint dysfunction, swallowing difficulties and other impairments.

REFERENCES 1.

American Association of Orthodontists - Orthodontic Glossary

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DETOXIFICATION

TITLE:

Chemical Dependency/Substance Abuse Detoxification

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 9/19/02, 12/5/02, 12/18/03, 12/15/04, 2/16/06, 2/14/08, 2/18/09, 2/17/10, 2/16/11, 02/23/12, 02/28/13

Policy Number: D-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Administrative Code 365:40-5-20 (7): (a) Diagnosis and medical treatment for the abuse of or addiction to alcohol and drugs including detoxification for alcoholism or drug abuse on either an outpatient or inpatient basis, whichever is medically determined to be appropriate, in addition to the other required basic health care services for the treatment of other medical conditions.

Members may have additional benefit coverage for alcohol and/or substance abuse detoxification. Refer to the member’s EOC/SOB or contact the Customer Service Department for member specific coverage and limitations.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

Inpatient coverage a. Alcohol and/or substance abuse detoxification in an acute care setting is covered for the acute stage of alcohol or substance abuse withdrawal when medical complications occur or are highly probable. 1) The inpatient hospital stay may be extended when medically necessary (see Medical Necessity policy). 2) There are no limits to the number of treatment episodes per year for detoxification. Outpatient coverage a. Medically necessary alcohol and/or substance abuse detoxification is covered. In most cases of substance abuse and/or alcohol and/or alcohol toxicity, outpatient treatment is appropriate unless another medical condition requires close inpatient monitoring.

D.

NOT COVERED 1.

Alcohol or drug rehabilitation services (other than detoxification), unless member has a supplemental chemical dependency benefit (see Rehabilitation: Chemical Dependency/Substance Abuse policy) 2. Acute inpatient detoxification for the main purpose of removing the member from his/her environment to prevent access to alcohol and/or substance abuse 3. Chemical or electrical aversion therapy 4. Electro-shock therapy, also known as electro-convulsive therapy (ECT), as treatment for alcoholism and/or chemical dependency 5. Meals, transportation and recreational/social activities for outpatient hospital services 6. Methadone maintenance or treatment unless mandated by State or Federal law as stated in Section A. 7. Non-medically necessary services required by the court as part of parole or probation, or instead of incarceration 8. Employer requested substance abuse testing 9. Rapid anesthesia opioid detoxification 10. Services that are not medically necessary for the treatment of substance abuse disorders E.

DEFINITIONS 1. 2. 3. 4.

F.

Abuse: Improper use of or physical and/or psychological addiction to alcohol or other substance. Chemical Dependency: An addictive relationship between a member and any drug, alcohol, or chemical substance. Detoxification: The period of time necessary to reduce the toxic level of a substance to a medically safe level. Substance: Alcohol or other substances such as narcotics and prescription or illegal drugs.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DEVELOPMENTAL DELAY and LEARNING DISABILITIES

TITLE:

Developmental Delay and Learning Disabilities

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 6/20/02, 6/18/03, 2/2/05, 2/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: D-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

This benefit interpretation policy applies to members with diagnosed or suspected developmental delay, either global or limited to a specific developmental area (e.g., speech/language, motor). A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2.

Assessment and coordination of care by the member's pediatrician or PCP (e.g., history, physical and management of medications) Referral for consultation and evaluation of individuals with suspected developmental and/or behavioral problems for confirmation of diagnosis

Also see Pervasive Developmental Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Mental Health: Outpatient, and Rehabilitation: Medical - Physical, Occupational and Speech Therapy policies D.

NOT COVERED

1.

2.

3.

Therapy for developmental delay is not covered except when the developmental delay is caused by a defined illness, disease, injury or surgery, e.g., congenital hypothyroidism, delay in speech due to documented hearing loss from ear infections. Note: Individuals should be referred to appropriate community resources for non-covered developmental delay therapies (e.g., school district, regional center) for these services. Assessment and therapy for learning disabilities (e.g., reading, mathematics and/or written expression disorders), except when the learning disability is caused by a defined illness, disease, injury or surgery. Other non-medical therapies or treatment programs. Examples include, but are not limited to: a. Non-crisis mental health counseling b. Behavior modification program c. Vocational and community living skills program d. Learning or reading disorders program e. Psychoanalysis f. Biofeedback g. Residential living programs h. Non-crisis family counseling i. Treatment by learning consultants, non-licensed health professionals and licensed counselors j. Music integration therapy k. Sensory Integration Therapy l. Coordination Therapy

Also see Pervasive Developmental Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Mental Health: Outpatient, and Rehabilitation: Medical - Physical, Occupational and Speech Therapy policies E.

DEFINITIONS 1. 2.

F.

Developmental Delay: Delayed attainment of age appropriate milestones in the areas of speechlanguage, motor, cognitive, and/or social development. Learning Disability: A condition that exists when there is a meaningful difference between a child's current academic level of function and the level that would be expected for a child of that age and intelligence level.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DIABETES

TITLE:

Diabetic Management, Services and Supplies

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 7/7/00, 9/1/00, 7/12/0, 6/20/02, 12/5/02, 3/20/03, 5/6/03, 12/15/04, 2/16/06, 2/14/08, 7/16/08, 10/28/08, 2/16/11, 11/09/11, 02/23/12, 02/28/13

Policy Number: D-010

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

Title 36 Oklahoma Statutes §6060.2 - Coverage for Diabetes A. 1. For policies, contracts or agreements issued or renewed on and after November 1, 1996, any individual or group health insurance policy, contract or agreement providing coverage on an expense-incurred basis; any policy, contract or agreement issued for individual or group coverage by a not-for-profit hospital service and indemnity and medical service and indemnity corporation; contracts issued by health benefit plans including, but not limited to, health maintenance organizations, preferred provider organizations, health services corporations, physician sponsored networks, or physician hospital organizations; medical coverage provided by self-insureds that includes coverage for physician services in a physician's office, including coverage through private third-party payors; coverage provided through the State and Education Employees Group Insurance Board; and every policy, contract, or agreement which provides medical, major medical or similar comprehensive type coverage, group or blanket accident and health coverage, or medical expense, surgical, medical equipment, medical supplies, or drug prescription benefits shall, subject to the terms of the policy contract or agreement, include coverage for the following equipment, supplies and related services for the treatment of Type I, Type II, and gestational diabetes, when medically necessary and when recommended or prescribed by a physician or other licensed health care provider legally authorized to prescribe under the laws of this state: a. blood glucose monitors, b. blood glucose monitors to the legally blind, c. test strips for glucose monitors, d. visual reading and urine testing strips, e. insulin, f. injection aids, g. cartridges for the legally blind, h. syringes,

i. insulin pumps and appurtenances thereto, j. insulin infusion devices, k. oral agents for controlling blood sugar, and l. podiatric appliances for prevention of complications associated with diabetes. 2. The State Board of Health shall develop and annually update, by rule, a list of additional diabetes equipment, related supplies and health care provider services that are medically necessary for the treatment of diabetes, for which coverage shall also be included, subject to the terms of the policy, contract, or agreement, if such equipment and supplies have been approved by the federal Food and Drug Administration (FDA). Such additional FDAapproved diabetes equipment and related supplies, and health care provider services shall be determined in consultation with a national diabetes association affiliated with this state, and at least three (3) medical directors of health benefit plans, to be selected by the State Department of Health. 3. All policies specified in this section shall also include coverage for: a. podiatric health care provider services as are deemed medically necessary to prevent complications from diabetes, and b. diabetes self-management training. As used in this subparagraph, "diabetes selfmanagement training" means instruction in an inpatient or outpatient setting which enables diabetic patients to understand the diabetic management process and daily management of diabetic therapy as a method of avoiding frequent hospitalizations and complications. Diabetes self-management training shall comply with standards developed by the State Board of Health in consultation with a national diabetes association affiliated with this state and at least three (3) medical directors of health benefit plans selected by the State Department of Health. Such coverage for diabetes self-management training, including medical nutrition therapy relating to diet, caloric intake, and diabetes management, but excluding programs the only purpose of which are weight reduction, shall be limited to the following: (1) visits medically necessary upon the diagnosis of diabetes, (2) a physician diagnosis which represents a significant change in the patient's symptoms or condition making medically necessary changes in the patient's self-management, and (3) visits when reeducation or refresher training is medically necessary; provided, however, payment for the coverage required for diabetes self-management training pursuant to the provisions of this section shall be required only upon certification by the health care provider providing the training that the patient has successfully completed diabetes self-management training. 4. Diabetes self-management training shall be supervised by a licensed physician or other licensed health care provider legally authorized to prescribe under the laws of this state. Diabetes self-management training may be provided by the physician or other appropriately registered, certified, or licensed health care professional as part of an office visit for diabetes diagnosis or treatment. Training provided by appropriately registered, certified, or licensed health care professionals may be provided in group settings where practicable. 5. Coverage for diabetes self-management training and training related to medical nutrition therapy, when provided by a registered, certified, or licensed health care professional, shall also include home visits when medically necessary and shall include instruction in medical nutrition therapy only by a licensed registered dietician or licensed certified nutritionist when authorized by the patient's supervising physician when medically necessary. 6. Such coverage may be subject to the same annual deductibles or coinsurance as may be

deemed appropriate and as are consistent with those established for other covered benefits within a given policy. B. 1. Health benefit plans shall not reduce or eliminate coverage due to the requirements of this section. 2. Enforcement of the provisions of this act shall be performed by the Insurance Department and the State Department of Health. 3. The provisions of this section shall not apply to: a. health benefit plans designed only for issuance to subscribers eligible for coverage under Title XVIII of the Social Security Act or any similar coverage under a state or federal government plan, b. a health benefit plan which covers persons employed in more than one state where the benefit structure was the subject of collective bargaining affecting persons employed in more than one state, and c. agreements, contracts, or policies that provide coverage for a specified disease or other limited benefit coverage. Also covered under HB #3021:

a.

B.

Podiatric health care provider services as are deemed medically necessary to prevent complications from diabetes

STATE MARKET PLAN ENHANCEMENTS

Note: Glucose monitors are covered under the member’s DME benefit; strips and lancets are covered under the pharmacy benefit. C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Notes: • See Section A for state-specific mandated coverage information. • For further information, see Clinical Practice Guidelines: Diabetes Management Guidelines (click Internal, Provider Portal or Member). • See Medical Management Guidelines: Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes; and Intermittent Intravenous Insulin Therapy (click Internal, Provider Portal or Member). • Supplemental Outpatient Prescription benefit required for coverage of insulin, glucagon and other diabetic medications. See Medications (Oral, Infusion, Injectable) and Off-Label Drug Use policy. 1.

Diabetic management and treatment, which include, but are not limited to: a. Education b. Medical nutritional therapy services c. Outpatient Diabetic Self-Management Training (ODSMT) Services Initial ODSMT IS recommended for members who, within the 12-month period prior to the physician's order for training, meet ONE OR MORE of the following criteria (CFR, 2003):

1. 2.

Newly diagnosed with diabetes Inadequate glycemic control demonstrated by a glycosylated hemoglobin (HbA 1c ) level of 7.0% or more on two consecutive HbA 1c determinations, 3 or more months apart in the year before the member begins receiving training 3. Change in treatment regime from no diabetic medications to any diabetic medication, or from oral diabetic medication to insulin 4. High-risk for complications based on inadequate glycemic control (documented acute episodes of severe hypoglycemia or acute severe hyperglycemia occurring in the past year during which the beneficiary needed emergency room visits or a hospitalization) 5. High-risk based on at least one of the following documented complications: a. Lack of feeling in the foot, or other complications such as foot ulcers, deformities, or amputation b. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye c. Kidney complications related to diabetes, when manifested by albuminuria, without other cause, or elevated serum creatinine Outpatient Diabetic Self-Management Training Program Requirements ODSMT must meet ALL of the following criteria: 1. Training must be provided by a physician, individual or entity accredited by the American Diabetes Association (ADA) to furnish outpatient diabetes selfmanagement training where physicians are accredited and programs are recognized. 2. Following an evaluation of the member's need for training, ODSMT must be ordered by the physician (or qualified licensed practitioner) treating the member's diabetes 3. ODSMT must be included in the comprehensive plan of care established by the physician (or qualified licensed practitioner). The treatment plan must meet the following requirements: a. Describes the content, number of sessions, frequency, and duration of the training as written by the physician (or qualified licensed practitioner) treating the member b. Provides that any changes to the plan of care are signed by the physician (or qualified licensed practitioner) treating the member c. Is incorporated into the approved entity's medical record for the member 4. ODSMT must be reasonable and necessary for treating or monitoring the condition of the member who meets the qualifying criteria listed above Training Classification Training is classified as either initial or follow-up (CFR, 2003) Initial Training 1. Furnished to the member who has not previously received initial training under this benefit 2. Furnished within a continuous 12-month period 3. Does not exceed a total of 10 hours 4. Nine (9) hours of the training are furnished in a group setting consisting of 2 to

20 individuals who need not all be UnitedHealthcare members 5. Furnished in increments no less than one-half hour 6. May include 1 hour of individual training for an assessment of the member's training needs Individual Training Training on an individual basis IS recommended when ANY of the following conditions are met: 1. No group session is available within 2 months of the date the training is ordered 2. The member's physician (or qualified licensed practitioner) documents in the member's medical record that the member has special needs resulting from conditions, such as severe vision, hearing, or language limitations that will hinder effective participation in a group training session. 3. Additional insulin instruction is needed (CMS, 2003)

2.

3.

4.

Follow-up Training Follow-up training must meet ALL OF the following criteria: 1. Consists of no more than 2 hours individual or group training for a member each year, where “group training” consists of 2 to 20 individuals who need not all be UnitedHealthcare members 2. It is furnished any time in a calendar year following the year in which the member completes the initial training 3. It is furnished in increments of no less than one-half hour 4. The physician (or qualified licensed practitioner) treating the member must document in the referral for training and the member's medical record, the specific medical condition that the follow-up training must address FDA approved medically necessary diabetic supplies and equipment for diabetics, including gestational diabetics, when prescribed or ordered by a physician (based upon the medical needs of the member) Note: The physician must determine that the member or home support person(s) can be trained in equipment use and monitor the blood glucose. a. Intermittent blood glucose monitors, blood-testing strips, and lancets b. Modified blood glucose monitors and supplies for the visually impaired (covered under the member’s DME benefit). The physician must certify that visual impairment is so severe that the member requires specific supplies, which include, but are not limited to: 1) Voice synthesizers 2) Automatic timers 3) Specially designed supplies to promote self-management Continuous subcutaneous insulin infusion pump (CSII) and related drugs and supplies are covered when medical criteria are met. Note: Payment may be made for drugs necessary for the effective use of an external infusion pump as long as the drug being used is in itself reasonable and necessary for the patient's treatment. Materials necessary for the function of the CSII pump that are not available over the counter (e.g., tubing, syringe reservoir, special needles)

5.

6.

D.

NOT COVERED 1.

2. 3. 4. 5. 6. 7. E.

Insulin, except when: a. Member has supplemental prescription drug benefit b. Used in conjunction with a continuous subcutaneous insulin infusion pump (CSII) Alcohol, alcohol wipes, betadine, betadine wipes or iodine, iodine wipes Cotton swabs, peroxide or phisohex Member does not meet criteria for requested services/supplies Implantable infusion pumps for the infusion of insulin Jet pressure powered type injectors unless covered under Section A or B Insulin injection aids (e.g., insulin pens) unless covered under Section A or B

DEFINITIONS 1. 2.

3.

4. F.

Podiatry services and devices to prevent or treat diabetes related complications for members with diabetic foot disease under the member’s medical plan (See Shoes and Foot Orthotics policy for coverage criteria. Also see Foot Care and Podiatry Services) Visual aids for members who have a visual impairment that would prohibit the proper dosing of insulin. Visual aids do not include eyeglasses (frames and lenses) or contact lenses. (See Vision Care and Services policy.)

Gestational Diabetes: A diabetic condition that appears during pregnancy (gestation). Gestational diabetes usually subsides after the birth of the baby. Type 1 Diabetes: This type of diabetes is primarily due to pancreatic islet - cell destruction, usually leading to absolute insulin deficiency. People with Type 1 diabetes must take daily insulin injections. Type 1 diabetes is also known as insulin dependent diabetes, immune-mediated diabetes or juvenile diabetes. Type 2 Diabetes: This type of diabetes is primarily due to insulin resistance with an insulin secretory defect that results in a relative (rather than absolute) insulin deficiency. It is the most common form of the disease. Type 2 diabetes is also known as non-insulin dependent diabetes, adult onset diabetes or insulin-resistant diabetes. Unstable Diabetic: A long-term diabetic with current management problems.

REFERENCES 1.

American Diabetes Association Clinical Practice Recommendations, Volume 22, Supplement 1, 1999

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DIALYSIS

TITLE:

Continuous Ambulatory Peritoneal Dialysis (CAPD)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 12/05/02, 1/14/04, 12/15/04, 8/17/06, 7/16/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: D-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2. 3. 4.

Continuous Ambulatory Peritoneal Dialysis (CAPD) performed either in an outpatient or home setting, including all equipment and supplies Drugs and biologicals generally covered for home dialysis, such as Epoetin, Heparin, and local anesthetics Routine CAPD laboratory tests Full range of general home dialysis support services, plus: a. Changing the connecting tube (administration set) b. Supervision of the member while performing CAPD, assuring that it is done correctly, reviewing for the member any aspects of the technique he/she has forgotten or informing the member of modification in apparatus or technique c. Documenting whether the member has or has had peritonitis that requires physician intervention or hospitalization d. Inspection of the catheter site

5.

D.

NOT COVERED 1. 2. 3. 4.

E.

Any laboratory test in excess of frequency defined under “routine laboratory tests” or any test that is not listed below is covered only if there is documentation of medical necessity Dialysis machine, water testing or water treatment Services performed in a non-approved ESRD facility Travel dialysis unless covered under Section B

DEFINITIONS 1.

2. 3. 4. 5.

F.

Examples include, but are not limited to: a. Start-up durable supplies (whether or not they are part of a start-up kit), such as weight scales, blood pressure apparatus (sphygmomanometer), IV stand, and dialysate heaters b. Consumable and disposable supplies, such as dialysate, tubing and gauze pads c. Members changing from another form of home dialysis to CAPD may have rental or lease purchase of home durable equipment up to three months after completing CAPD training course

Continuous Ambulatory Peritoneal Dialysis: A form of peritoneal dialysis that was developed as an alternative method of dialysis for home dialysis members. It is a continuous dialysis process that uses the member’s peritoneal membrane as a dialyzer and requires the implanting of an in-dwelling catheter to provide access to the peritoneum. Home Dialysis: Peritoneal dialysis or hemodialysis performed by an ESRD member after completion of an approved training program. Peritoneal Dialysis: A type of dialysis where the filtering takes place within the member’s abdominal cavity without the blood leaving the body. Peritoneal Membrane: The membrane lining the abdominal cavity that covers most of the organs found in the abdomen. Routine Laboratory Tests: Tests that need to be performed for kidney dialysis members on a monthly basis (BUN, Creatinine, Sodium, Potassium, CO2, Calcium, Magnesium, Phosphate, Total Protein, Albumin, Alkaline Phosphatase, LDH, AST, SGOT, HCT, Hgb, Dialysate Protein); every three months (WBC, RBC, Platelet count); and every six months (residual renal function and 24-hour urine volume).

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DIALYSIS

TITLE:

End Stage Renal Disease (ESRD)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 5/31/01, 5/6/03, 12/15/04, 8/17/06, 7/16/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: D-006

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Acute and chronic hemodialysis services and supplies are covered. Examples include, but are not limited to: a. Maintenance of chronic dialysis (peritoneal or hemodialysis) furnished in a provider based or independently operated ESRD facility approved under the ESRD program within the service area only, except for emergency out-of-area services ( see Emergency and Urgent Services policy). The services must be authorized by UnitedHealthcare or the member’s Primary/Contracting/Participating Medical Group. b. Hemodialysis services in an outpatient dialysis center c. Dialysis services while hospitalized d. Hemodialysis or peritoneal dialysis in the home, including equipment and supplies necessary to perform all areas of home dialysis (see Dialysis: Continuous Ambulatory Peritoneal Dialysis (CAPD) policy e. Training of a home dialysis member and/or family member/ significant other, including review

f.

of family and home status, environment, and counseling/training of family members Ambulance transportation to or from dialysis facility only when an ambulance level of transportation is medically necessary and other means of transportation are contraindicated or when the member is an inpatient in an acute hospital or skilled nursing facility (SNF) that cannot provide the services for the member (see Ambulance Transportation policy)

Note: For chronic hemodialysis, application for Medicare Part A and Part B coverage must be made. D.

NOT COVERED 1.

E.

DEFINITIONS 1. 2.

3. 4. 5.

6. 7.

F.

Non-emergent out-of-area dialysis services

Dialysis: The process in which waste products are removed from the body by diffusion from one fluid compartment to another through a semi-permeable membrane. End Stage Renal Disease (ESRD): The final stage of kidney disease where kidney function is irreversible and permanent and requires a regular course of dialysis or a kidney transplantation to maintain life. ESRD is also known as chronic renal failure (CRF). Hemodialysis: The most widely used type of dialysis, hemodialysis filters the blood through a kidney machine, where waste is removed before the blood is returned to the body. Home Dialysis: Peritoneal or hemodialysis performed by the ESRD member who has completed an appropriate training course. Maintenance Dialysis: The usual periodic dialysis treatments that are given to a patient who has end stage renal disease in order to sustain life and ameliorate uremic symptoms. Maintenance peritoneal and hemodialysis is generally required 2 to 3 times per week, but less frequent treatments are sometimes adequate. Peritoneal Dialysis: Another form of dialysis in which filtering takes place within the member’s abdominal cavity where waste is filtered by the peritoneal membrane. Self-Dialysis: Dialysis performed with little or no professional assistance by an ESRD member who has completed an appropriate training course. This treatment may be performed on an inpatient or outpatient basis.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

DURABLE MEDICAL EQUIPMENT (DME), PROSTHETICS, CORRECTIVE APPLIANCES/ORTHOTICS (NON-FOOT ORTHOTICS) AND MEDICAL SUPPLIES

TITLE:

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 3/1/01, 1/14/04, 6/23/04, 11/18/04, 7/21/05, 11/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: D-009

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

See DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies Grid for specific State Mandates

See DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies Grid for specific Market Plan Enhancements

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2.

See DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies Grid for the list of covered items and specific coverage criteria. DME items, prosthetic devices and corrective appliances/orthotics a. DME items may be rented or purchased and must meet all of the following criteria: 1) The equipment meets the definition of DME (see Section E). 2) The equipment is necessary and reasonable for the treatment of the member's illness or injury or to improve the functioning of his/her malformed body member. 3) The equipment is used in the member's home (see Section E).

b.

3.

Prosthetic devices and corrective appliances/orthotics must meet all of the following criteria: 1) The item meets the definition of prosthetic (see Section E). 2) The item is furnished on a physician's order. c. Supplies for DME items or prosthetic devices (e.g., oxygen, batteries for an artificial larynx, stump sock or shrinker) only when they are necessary for the effective use of the item/device d. Repairs, replacement and maintenance of DME items, prosthetic devices and corrective appliances/orthotics for owned, purchased or rented equipment (Note: Repairs, replacement and maintenance for rented items/devices are the contractual responsibility of the item/device provider.) 1) May require pre-certification to be covered (Note: The Market pre-certification process varies) 2) Repairs, including the replacement of essential accessories, such as hoses, tubes, mouth pieces, etc., for necessary DME are covered when necessary to make the item/device serviceable and the estimated repair expense does not exceed the cost of purchasing or renting another item/device a) Extensive maintenance is covered as repair when, based on the manufacturer's recommendations, the maintenance (e.g., breaking down sealed components, performing tests that require specialized testing equipment not available to the member) is to be performed by an authorized technician 3) Adjustment of prosthetic devices or corrective appliances/orthotics, when required by wear or a change in the patient's condition and ordered by a physician 4) Replacements are covered for damage beyond repair with normal wear and tear, when repair costs exceed new purchase price, or when a change in the member’s medical condition occurs. a) Replacement of artificial limbs or any part of such devices is covered when the condition of the device or part requires repairs that cost more than 60% of the cost of a replacement device or part Medical supplies a. Medical supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness. Note: Medical supplies may not be billed as implantable devices (see Section E for definition).

Also see Shoes and Foot Orthotics policy. D.

NOT COVERED 1. 2. 3. 4. 5. 6.

See DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies Grid for the list of non-covered items Routine periodic maintenance (e.g., testing, cleaning, regulating and checking equipment) for which the owner is generally responsible Replacement of items due to malicious damage, neglect or abuse (Note: See Section B for additional benefit information.) Replacement of lost or stolen DME (Note: See Section B for additional benefit information.) Additional accessories or attachments to DME, corrective appliances/orthotics or prosthetics for comfort or convenience of the member, including home and vehicle remodeling or modification Bionic, myoelectric, microprocessor-controlled or computerized prosthetics

7.

A second piece of equipment with or without additional accessories that is for the same or similar medical purpose as existing equipment 8. Medical supplies that are disposable or can be consumed other than defined above or are part of the Home Health benefit. (See Home Health policy)

E.

DEFINITIONS 1.

2.

3.

4. 5.

6.

F.

Corrective Appliances/Orthosis: Devices that are designed to support a weakened body part. These appliances/orthosis are manufactured or custom-fitted to an individual member. [This definition does not include foot orthotics or specialized footwear which may be covered for members with diabetic foot disease.] Durable Medical Equipment (DME): Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home. Implantable Devices: Defined by the FDA as a device that is placed into a surgically or naturally formed cavity of the human body if the device is intended to remain there for a period of 30 days or more. In order to protect public health, the FDA may determine that devices placed in subjects for shorter periods of time are also implants. These devices are used as an integral and subordinate part of the procedure performed, are used for one patient only, are single use, come in contact with human tissue, and are surgically implanted or inserted whether or not they remain with the patient when the patient is released from the hospital outpatient department. The following are not considered to be implantable devices: sutures, customized surgical kits, or clips, other than radiological site markers, furnished incident to a service or procedure. They are also not materials such as biologicals or synthetics that may be used to replace human skin. Medical Supplies: Expendable items required for care related to a medical illness or dysfunction. Member's Home: For the purposes of rental and purchase of DME, a member's home may be his own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered a member's home if it: a. Meets at least the basic requirement in the definition of a hospital (i.e., it is primarily engaged in providing, by or under the supervision of physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled and sick persons, or rehabilitation services for the rehabilitation of injured, disabled or sick persons). b. Meets at least the basic requirement in the definition of a skilled nursing facility (i.e., it is primarily engaged in providing skilled nursing care and related services to inpatients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled or sick persons). Prosthetic Devices: Durable, custom-made devices designed to replace all or part of a permanently inoperative or malfunctioning body part or organ. Examples of covered prosthetics include initial contact lens in an eye following a surgical cataract extraction and removable, nondental prosthetic devices such as a limb that does not require surgical connection to nerves, muscles or other tissue.

REFERENCES

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Refer to the Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies policy for the definitions of prosthesis, corrective appliances/orthotics and medical supply.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness. ITEM Abdominal binder

Surgical Non-surgical

Aero Chamber (spacer)

COVERAGE Medical Supply* Corrective Appliance/Orthotic

COMMENTS Only when used as a dressing/holder; also see Dressings, Surgical Covered when all of the following criteria are met: 1) Serves a medical purpose and it is only associated with treating an illness, injury or malformed body member; 2) Provides support and counter force (a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that is being used to brace; 3) Not used to supply compression therapy (e.g. to reduce size, volume, or swelling of a body member or to help circulation) 4) Not used for convenience or appearance 5) Not used for cosmetic purposes

Medical Supply*

Air Cleaner/Purifier

Not covered

EOC Exclusion. Environmental control, not primarily medical in nature

Air Conditioner

Not covered

EOC Exclusion. Environmental control, not primarily medical in nature

Air-fluidized Bed (Bead), e.g., Clinitron

DME

Home use of an air-fluidized bed IS recommended when all of the following criteria are met: 1. The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 2. 3. 4.

The patient is bedridden or chair bound as a result of severely limited mobility The patient would require institutionalization in the absence of an airfluidized bed The air-fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive assessment and evaluation of the patient after completion of a course of conservative treatment designed to optimize conditions that promote wound healing a. The conservative treatment course must have been at least one month in duration without progression toward wound healing. The month of conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment has been rendered b. Conservative treatment must include: 1) Frequent repositioning of the patient with particular attention to relief of pressure over bony prominences (usually every 2 hours) 2) Use of a specialized support surface (Group 2) designed to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation 3) Necessary treatment to resolve any wound infection 4) Optimization of nutrition status to promote wound healing 5) Debridement by any means (including wet to dry dressings, which does not require an occlusive covering) to remove devitalized tissue from the wound bed 6) Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 5.

6. 7.

covering, while the wound heals A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered status, dietary needs, prescribed treatments, and management and support of the airfluidized bed system and its problems, such as leakage A physician directs the home treatment regimen and re-evaluates and re-certifies the need for the air-fluidized bed on a monthly basis All other alternative equipment has been considered and ruled out

Home use of an air-fluidized bed IS NOT recommended under any of the following circumstances: 1. The patient has co-existing pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions) 2. The patient requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering, such as plastic wrap or other occlusive material 3. The caregiver is unwilling or unable to provide the type of care required by the patient on an air-fluidized bed 4. Structural support is inadequate to support the weight of the airfluidized bed system, which generally weighs 1,600 pounds or more 5. Electrical system is insufficient for the anticipated increase in energy consumption Air Splint

Medical Supply*

Clear plastic splints inflated by air used temporarily on fractured, broken, crushed or burned limbs.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

Alternating Pressure Pads, Gel Flotation Devices, Lambs Wool Pads/Sheep Skins (Group 1 pressure reducing support surfaces)

DME

COMMENTS Covered if the member meets: Criterion 1, or Criteria 2 or 3 and at least one of criteria 4-7. 1) 2) 3) 4) 5) 6) 7)

Alternating Pressure Pads, Low Air Loss or Powered Flotation without Low Air Loss (Group 2 pressure reducing support surfaces)

DME

Completely immobile - i.e., member cannot make changes in body position without assistance. Limited mobility - i.e., member cannot independently make changes in body position significant enough to alleviate pressure. Any stage pressure ulcer on the trunk or pelvis. Impaired nutritional status. Fecal or urinary incontinence. Altered sensory perception. Compromised circulatory status.

Mattresses (Pressure Reducing) ARE recommended if the patient meets the following: 1. Criterion a and b and c, or 2. Criterion d, or 3. Criterion e and f Criteria: a. Multiple stage II pressure ulcers (see Appendix I for details) located on the trunk or pelvis b. Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate Group 1 support surface. The comprehensive treatment should include the following: 1) Education of the patient and caregiver on the prevention and/or management of pressure ulcers

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

c. d. e. f.

2) Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer) 3) Appropriate turning and positioning 4) Appropriate wound care (for a stage II, III, or IV ulcer) 5) Appropriate management of moisture/incontinence 6) Nutritional assessment and intervention consistent with the overall plan of care The ulcers have worsened or remained the same over the past month. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) The patient has been on a Group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

Note: If the patient is using a Pressure Reducing Mattress, there should be a care plan established by the physician or home care nurse, which includes the elements listed above. The support surface provided for the patient should be one in which the patient does not "bottom out.” Bottoming out is the finding that an outstretched hand can readily palpate the bony prominence (coccyx or lateral trochanter) when it is placed palm up beneath the undersurface of the mattress or overlay and in an area under the bony prominence. The bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position. *Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

COVERAGE

ITEM

COMMENTS Note: When a Pressure Reducing Mattress is provided following a myocutaneous flap or skin graft, recommendation generally is limited to 60 days from the date of surgery. Continued Use Continued use of a Pressure Reducing Mattress IS recommended until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show the following: 1. Other aspects of the care plan are being modified to promote healing, or 2. The use of the Pressure Reducing Mattress is medically necessary for wound management

Ambulatory Boot

Ankle-Foot Non-ambulatory Orthosis (AFO)/KneeAnkle-Foot Orthosis (KAFO)

Ankle contracture splint

Corrective Appliance/Orthotic

Also known as surgical boot

Corrective Appliance/Orthotic

Covered if either all criteria 1-4 or criterion 5 is met: 1. plantar flexion contracture of the ankle with a dorsiflexion on passive range of motion testing of at least 10 degrees 2. reasonable expectation of the ability to correct the contracture 3. contracture is interfering or expected to interfere significantly with the patient's functional abilities 4. used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons. 5. member has plantar fasciitis

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

COVERAGE

ITEM Foot drop splint

Ambulatory (e.g., cam walkers, pneumatic splint)

Not Medically Necessary Corrective Appliance/Orthotic

COMMENTS More appropriate treatment modalities exist (e.g., ambulatory AFOs).

Ankle-foot orthoses (AFO) are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally. Knee-ankle-foot orthoses (KAFO) are covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required. AFO, KAFO, and braces for ankle, foot, and knee used solely for athletic sports are not covered. AFOs and KAFOs that are molded-to-patient-model are covered for ambulatory patients when the basic coverage criteria listed above are met and one of the following criteria are met: 1. The patient could not be fit with a prefabricated AFO, or 2. The condition necessitating the orthosis is expected to be permanent or of long standing duration (more than 6 months), or 3. There is a need to control the knee, ankle or foot in more than 1 plane, or 4. There is a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or 5. The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

Apnea Monitor (Infant or Child)

Artificial Eye

DME

There must be documentation of sleep apnea by a sleep study and a history of apnea events. Rental only. Not covered for adults.

Prosthetic

Covered for member with absence or shrinkage of an eye due to birth defect,

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS trauma or surgical removal. Coverage includes polishing and resurfacing. Orbital implants are reimbursed as surgical implants.

Artificial Larynx or Electronic Speech Aid

Prosthetic

Coverage for member post laryngectomy or permanently inoperative larynx condition; disposable aid not covered There are two types of speech aids. One operates by placing a vibrating head against the throat; the other amplifies sound waves through a tube which is inserted into the user's mouth. A patient who has had radical neck surgery and/or extensive radiation to the anterior part of the neck would generally be able to use only the "oral tube" model or one of the more sensitive and more expensive "throat contact" devices.

Artificial Limbs Standard – Lower Limb

Prosthetic

Case by case basis. A lower limb prosthesis IS recommended in the following instances: 1. The patient will reach or maintain a defined functional state within a reasonable period of time; and 2. The patient is motivated to ambulate Functional Levels: A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist and treating physician, considering factors including, but not limited to: 1. The patient's past history (including prior prosthetic use if applicable); and 2. The patient's current condition including the status of the residual limb and the nature of other medical problems; and

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 3.

The patient's desire to ambulate

Clinical assessments of patient rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. Note: The records must document the patient's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. Within the functional classification hierarchy, bilateral amputees often cannot be strictly bound by functional level classifications. General: *Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS Prostheses should be furnished incident to physicians' services or on a physician's order. Accessories (e.g., stump stockings for the residual limb, harness, including replacements) are also recommended when these appliances aid in or are essential to the effective use of the artificial limb. Note: Lower limb prostheses are not recommended for patients with functional level 0. Feet: A determination of the type of foot for the prosthesis should be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a SACH foot. Other prosthetic feet should be considered based upon functional classification: 1. An external keel SACH foot or single axis ankle/foot is recommended for patients whose functional level is 1 or above 2. A flexible-keel foot or multiaxial ankle/foot is recommended for patients whose functional level is 2 or above 3. A flex foot system, energy storing foot, multiaxial ankle/foot, dynamic response, or flex-walk system or equal, or shank foot system with vertical loading pylon, is recommended for patients whose functional level is 3 or above Knees: A determination of the type of knee for the prosthesis should be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS should include a single axis, constant friction knee. Other prosthetic knees should be considered based upon functional classification. Note: Before using this recommendation please review the Member/Enrollee coverage documents(EOC, Certificate, SOB,BIP); some Member/Enrollees do not have coverage for Microprocessor, Myoelectric or Bionic Prosthetics. 1. A high activity knee control frame is covered for patients whose functional level is 4. 2. A fluid, pneumatic, or electronic prosthetic knee is recommended for patients whose functional level is 3 or above 3. Other standard knee systems not fitting categories above are recommended for patients whose functional level is 1 or above Ankles: An axial rotation unit IS recommended for patients whose functional level is 2 or above. Sockets: Test (diagnostic) sockets for immediate prostheses are not medically necessary. No more than 2 test (diagnostic) sockets for an individual prosthesis are medically necessary without additional documentation. No more than two of the same socket inserts should be provided per individual prosthesis at the same time. Socket replacements are considered medically necessary if there is adequate documentation of functional and/or physiological need. There are situations where the explanation includes, but is not limited to, changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of very active

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS amputees. Accessories (e.g., stump stockings, harness, shrinkers) are covered when essential to the effective use of the artificial limb. Six (6) stump socks per limb covered initially with replacements as needed due to normal wear and tear.

Bionic

Not covered

EOC Exclusion.

C-leg (microprocessor-controlled kneeshin system)

Not covered

EOC/SOB Exclusion.

Artificial Limbs Standard – Upper Limb

Note: Members may have coverage for this item under the prosthetic benefit in some plans. Refer to the member's EOC/SOB or contact the Customer Service Department to determine coverage eligibility. Prosthetic

Case by case basis; A determination of the medical necessity for the prosthesis is based on the patient's potential functional abilities. Potential function ability is based on the reasonable expectations of the prosthetist and treating physician, considering factors including, but not limited to, the following: The patient's past history (including prior prosthetic use if applicable); and The patient's current condition including the status of the residual limb and the nature of the other medical problems; and The patient's desire to use a prosthesis Body Powered Prostheses - Upper Limb Upper limb functional body-powered prostheses are powered and controlled by gross body movements, a harness, and cable system. The following are basic requirements necessary for a patient to be a candidate for a body-powered prosthesis:

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 1. Sufficient residual limb length 2. Sufficient musculature 3. Sufficient range of motion A patient must possess at least one more of the following gross body movements to be able to control a body-powered prosthesis: 1. Glenohumeral flexion 2. Scapular abduction or adduction 3. Chest expansion 4. Shoulder depression and elevation

Myoelectronic

Not Covered

Back Brace

See Spinal Orthosis

Back Support (chair) Bath Accessories

Beds and Accessories

EOC Exclusion

Not covered

Not primarily medical in nature

Bath Tub Lifts and Seats

Not covered

Not primarily medical in nature

Transfer Bench

Not covered

Not primarily medical in nature

Hospital, fixed height

DME

Member must meet one or more of the following criteria. • • •

Requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed. Require positioning of the body in ways not feasible with an ordinary bed, for alleviation of pain Require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS •

with aspiration (pillows or wedges should be considered first) Require traction equipment that can only be attached to a hospital bed

Hospital, variable height

DME

Member must meet one of the criteria for the fixed height bed (as listed above) and must require a bed height different than a fixed height bed in order to permit transfer to a chair, wheelchair or standing position

Hospital, semi-electric

DME

Member must meet one of the criteria for the fixed height bed (as listed above) and must require frequent or immediate changes in body position

Hospital, total electric

Not covered

The electric height adjustment feature is a convenient item therefore does not meet the definition of DME.

DME

Recommended for patients meeting criteria for a fixed height hospital bed and the patient’s weight is more than 350 pounds, but does not exceed 600 pounds The criteria for a fixed height hospital bed are considered met if ONE OR MORE of the following is present: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out 4. The patient requires traction equipment, which can only be attached to a hospital bed

Hospital, heavy duty extra wide

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM Hospital, extra heavy duty

COVERAGE DME

COMMENTS Recommended for patients meeting criteria for a fixed height hospital bed and the patient’s weight exceeds 600 pounds The criteria for a fixed height hospital bed are considered met if ONE OR MORE of the following is present: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out 4. The patient requires traction equipment, which can only be attached to a hospital bed

Lounge (power or manual) Mattress

Not covered

Not primarily medical in nature

DME

Only when part of a hospital bed

Oscillating

Not covered

Institutional equipment; inappropriate for home use. Does not meet the definition of DME.

Over Bed Tables

Not covered

Not primarily medical in nature

Pressure Reducing

DME

Mattresses (Pressure Reducing) ARE recommended if the patient meets the following: 1. Criterion a and b and c, or 2. Criterion d, or

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 3.

Criterion e and f Criteria: a. Multiple stage II pressure ulcers (see Appendix I for details) located on the trunk or pelvis b. Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate Group 1 support surface. The comprehensive treatment should include the following: 7) Education of the patient and caregiver on the prevention and/or management of pressure ulcers 8) Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer) 9) Appropriate turning and positioning 10) Appropriate wound care (for a stage II, III, or IV ulcer) 11) Appropriate management of moisture/incontinence 12) Nutritional assessment and intervention consistent with the overall plan of care c. The ulcers have worsened or remained the same over the past month. d. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis e. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) f. The patient has been on a Group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS Note: If the patient is using a Pressure Reducing Mattress, there should be a care plan established by the physician or home care nurse, which includes the elements listed above. The support surface provided for the patient should be one in which the patient does not "bottom out.” Bottoming out is the finding that an outstretched hand can readily palpate the bony prominence (coccyx or lateral trochanter) when it is placed palm up beneath the undersurface of the mattress or overlay and in an area under the bony prominence. The bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position. Note: When a Pressure Reducing Mattress is provided following a myocutaneous flap or skin graft, recommendation generally is limited to 60 days from the date of surgery. Continued Use Continued use of a Pressure Reducing Mattress IS recommended until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show the following: 1. Other aspects of the care plan are being modified to promote healing, or 2. The use of the Pressure Reducing Mattress is medically necessary for wound management

Siderails

DME

Only if part of hospital bed and member’s condition requires bed siderails.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Bed Baths (home type)

Not covered

Not primarily medical in nature

Bed Board

Not covered

Not primarily medical in nature

Bed Lifter (bed elevator)

Not covered

Not primarily medical in nature

Bed Cradle

DME

Covered when necessary to prevent contact with the bed coverings.

Bed Pan (autoclavable, hospital type)

DME

If member is bed bound

Bed Specs (prism glasses)

Not covered

Not primarily medical in nature.

Bed Wetting Alarms

Not covered

Not primarily medical in nature

Bilevel Positive Airway Pressure (BiPAP)

DME

Bili-lights/Bili-blankets

DME

Blood Glucose Analyzer-reflectance Colorimeter

Not covered

Covered when medical criteria are met. See Sleep Apnea policy.

Unsuitable for home use. Does not meet the definition of DME.

Blood Pressure Monitor /Sphygmomanometer

DME

Only for members on home dialysis; fully and semi-automatic (member activated) portable monitors are not covered.

Bone Stimulator also known as Osteogenic Stimulator (Electronic or Ultrasonic)

DME

Criteria apply; see MMG: Electrical and Ultrasound Bone Growth Stimulators (click Internal, Provider Portal or Member). Also see Osteogenic/Bone Stimulation Policy.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Market: UnitedHealthcare of Oklahoma, Inc.

ITEM Braces

COVERAGE Corrective Appliance/Orthotic

Braille Teaching Text

Not covered

COMMENTS Excludes orthodontic braces; also see AFO/KAFO or Knee Orthosis or Spinal Orthosis (body jacket) or Back Brace Educational, not primarily medical in nature

Bras (post surgery)

Prosthetic

Two covered initially, with replacements thereafter due to normal wear and tear; coverage includes custom fittings

Breast Prosthesis (external)

Prosthetic

Covered for members who have had a mastectomy or lumpectomy. See Surgery: Post-Mastectomy Services policy. Initial prosthesis is covered for the useful lifetime of the prosthesis, with replacements thereafter due to normal wear and tear. Replacement of the same type is covered at any time when it’s lost or irreparably damaged.

Breast-feeding Support, Supplies and Counseling

DME

Cam Walkers (also known as Walking Boot) Canes

Quad or Straight

Under the health reform law, lactation support and counseling as well as costs for renting breast-feeding equipment for each child’s birth are covered at no costshare. In addition to covering the cost of rental, UnitedHealthcare will cover the purchase of a personal, double-electric breast pump at no cost to the member. To rent or purchase breast pumps, members will simply need to contact a network physician or durable medical equipment (DME) supplier. The physician or DME supplier will bill UnitedHealthcare directly for reimbursement. Member’s will not be able to purchase supplies, such as breast pumps, at rental and send the receipt for reimbursement See Ankle Foot Orthosis (AFO)/Knee Ankle Foot Orthosis (KAFO)

DME

Covered if condition impairs ambulation and there is potential for ambulation.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM White Car Seats Casts (e.g., plaster, fiberglass) Catheters and Supplies

COVERAGE

COMMENTS

Not covered

Not primarily medical in nature.

Not covered

Not primarily medical in nature.

Medical Supply*

Used to reduce fractures or dislocations.

Closed Drainage Bags

Prosthetic

Only for members with nonfunctioning bladder or permanent incontinence as medically required

External Urinary Collection Devices (e.g., male external catheters and female pouches/meatal cups)

Prosthetic

Only for members with nonfunctioning bladder or permanent incontinence when used as an alternative to an indwelling catheter. Male external catheters are limited to no more than 35 per month and female external urinary collection devices are limited to no more than one meatal cup per week or one pouch per day. Requests for a greater quantity must be documented by a participating physician as medically necessary.

Foley/Indwelling

Prosthetic

Only for members with nonfunctioning bladder or permanent incontinence as medically required. Limited to no more than one catheter per month for routine catheter maintenance. Requests for a greater quantity must be documented by a participating physician as medically necessary.

Intermittent Urinary Catheters

Prosthetic

Intermittent catheterization is covered when basic coverage criteria are met and the patient or caregiver can perform the procedure. When clean, non-sterile catheterization technique is used, replacement of intermittent catheters on a weekly basis is covered unless there is documentation of

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS the medical necessity for more frequent replacement. Non-sterile lubricating gel is covered for up to 8 units of service (8 oz.) per month. An individual packet of lubricant is not covered. Intermittent catheterization using sterile technique is covered when the patient requires catheterization and the patient meets one of the following criteria (1-5): 1. The patient resides in a nursing facility 2. The patient is immunosuppressed (e.g., on a regimen of immunosuppressive drugs post-transplant) 3. The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization, 4. The patient is a spinal-cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only), 5. The patient has had distinct, recurrent urinary tract infections, while on a program of clean intermittent catheterization, twice within the 12-month prior to the initiation of sterile intermittent catheterization. Note: The medical necessity for use of sterile intermittent catheterization for reasons other than the criteria (1-5) listed above may be presented for individual consideration. For each episode of covered sterile catheterization, one catheter and an individual packet of lubricant or an intermittent catheter kit are covered.

Leg Drainage Bags

Cervical Collar

Semi-rigid

Prosthetic

Corrective Appliance/Orthotic

Only for members with nonfunctioning bladder or permanent incontinence who are ambulatory or are chair or wheelchair bound. Provides increased cervical support over foam

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Soft

Corrective Appliance/Orthotic

Minimal cervical support for sprains/strains

Rigid

Corrective Appliance/Orthotic

Covered post-surgery

Cervical Pillow

Not covered

Cervical Thoracic Lumbar Sacral Orthoses (CTLSO) Chair (adjustable)

Not primarily medical in nature. See Spinal Orthosis; also see Scoliosis Orthosis

DME

Chemical Test Strips

Only for members on home dialysis; see End Stage Renal Disease (ESRD) policy See Diabetic Management, Services and Supplies policy

Clavicle Support/Splint

Corrective Appliance/Orthotic

Cleft Palate Prosthesis

Prosthetic

Only for cleft lip and palate deformities as a result of congenital malformation

Cochlear Implant (External Component of Device)

Prosthetic

Considered as high-end prosthetic device. Criteria apply; see Hearing policy, MMG: Cochlear Implants (click Internal, Provider Portal or Member).

Cold Therapy • •

Not covered

Used to keep the clavicle in position following acute injury or post operative care.

Not medically necessary. Alternative therapy available with the same outcomes.

Cold Packs /Cool Jackets Water circulating cold pad with pump (e.g., Polar Units)

Collagen Implant

Prosthetic

See Incontinence Control (Adult) policy.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM Colostomy Bag Commode (without wheels only)

COVERAGE Prosthetic

Bedside

DME

Chair Foot Rest

Not covered

Elevated Seat (raised toilet seat)

Not covered

Communication Devices (e.g.,, computers, personal digital assistants, speech generating devices)

Not covered

Compression Garments / Bandages

DME

COMMENTS See Ostomy Supplies policy Covered when member is physically incapable of utilizing regular toilet facilities. This would occur when (1) member is confined to a single room, or (2) member is confined to one level of the home environment and there is not toilet on that level, or (3) member is confined to the home and there are no toilet facilities in the home.

EOC Exclusion Pneumatic compression devices consist of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Pneumatic Compression Devices ARE recommended for the following indications: 1.

Lymphedema – for the treatment of lymphedema in the home setting if the patient has undergone a 4-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise and

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

2.

elevation of the limb. The garment may be prefabricated or customfabricated but must provide adequate graduated compression Chronic venous insufficiency (CVI)*

Pneumatic compression devices must be prescribed by a physician and used with appropriate physician oversight (i.e., physician evaluation of the patient’s condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment). The determination by the physician of the medical necessity of a pneumatic compression device must include all of the following: 1. The patient’s diagnosis and prognosis 2. Symptoms and objective findings, including measurements which establish the severity of the condition 3. The reason the device is required, including the treatments which have been tried and failed 4. The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home A segmented, calibrated gradient pneumatic compression device is recommended only when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber. *Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS * Chronic Venous Insufficiency (CVI): CVI of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema and venous ulcers.

Contact Lens, Hydrophilic Soft (external)

Covered under the medical benefit. Coverage criteria apply. See Vision Care and Services policy.

Continuous Passive Motion (CPM)

DME

Refer to MMG: Mechanical Stretching and Continuous Passive Motion Devices (Internal, Provider Portal or Member).

Continuous Positive Airway Pressure (CPAP)

DME

Covered when medical criteria are met. See Sleep Apnea policy.

Corset Cough Assist Devices

Corrective Appliance/Orthotic DME

Mechanical in-exsufflation devices are covered for patients who meet both of the following criteria: 1) They have a neuromuscular disease, and 2) This condition is causing a significant impairment of chest wall and/or diaphragmatic movement, such that it results in an inability to clear retained secretions.

Crutches, Crutch Tips and Handles

DME

Covered if condition impairs ambulation and there is potential for ambulation. Note: Platform Crutch is a non-covered item as it is not deemed a medical necessity.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM Dehumidifier

COVERAGE Not covered

COMMENTS Environmental control, not primarily medical in nature

Dental Splint

See Splints

Diabetic Supplies (e.g., glucometer, lancets, injection aids)

See Diabetic Management, Services and Supplies policy

Dialysis Home Kit, Peritoneal

DME

Only for members on home dialysis

Diapers

Not covered

Hygienic supplies, non-reusable

Disposable Sheets

Not covered

Hygienic item; non-reusable disposable supplies

Dressings/ Bandages

Non-surgical Dressings/Bandages (e.g., Ace bandages)

Medical Supply*

Only when provided in the physician’s office, otherwise considered over the counter

Surgical Dressings

Medical Supply*

Surgical dressings are limited to primary dressings (therapeutic or protective coverings applied directly to a wound) or secondary dressings (dressings that serve a therapeutic or protective function and are needed to secure a primary dressing, e.g., tape, roll gauze, transparent film) that are medically necessary for the treatment of a wound caused by, or treated by, a surgical procedure or wound debridement.

DME Prosthetic

Surgical dressings may be covered as: • Medical supply when provided the physician’s office. • DME when ordered by the treating physician or other healthcare professional for the patient’s home use in conjunction with a durable medical equipment (e.g., infusion pumps) • Prosthetic when ordered by the treating physician or other healthcare *Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS professional for the patient’s home use as dressing for surgical wound or for wound debridement or in conjunction with a prosthetic device (e.g., tracheostomy).

Easy Stand/Tilt Stand

Not covered

Not primarily medical in nature

Egg Crate

Not covered

See Alternating Pads

Elbow Orthosis

Electrical Stimulation Devices (for chronic pain)

Corrective Appliance/Orthotic

Used for compression of tissue or to limit motion. Custom molded covered only when member cannot be fitted with a prefabricated elbow support

H-wave Stimulation Device

Not Medically Necessary

Insufficient clinical evidence supporting effectiveness.

Interferential Device

Not Medically Necessary

Refer to MMG: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (click Internal, Provider Portal or Member).

Tens Unit

DME

Covered for: 1. Treatment of members with chronic, intractable pain that has been present for at least 3 months and after other appropriate treatment modalities have been tried and failed or; 2. Treatment of acute post-operative pain , usually limited to 30 days from surgery and 3. Appropriate trial and successful use must be demonstrated. 4. Electrodes and patches are included. Presumed etiology of the pain must be a type that is accepted as responding to TENS therapy.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Market: UnitedHealthcare of Oklahoma, Inc.

ITEM

COVERAGE

Electrical Stimulation Devices (Neuromuscular, NMES)

DME

Electrical Stimulation Devices or Electromagnetic Therapy for Wound Healing or Diathermy Machines (e.g. Diapulse)

Not covered

Electronic Speech Aids

COMMENTS Coverage criteria apply; see MMG: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (click Internal, Provider Portal or Member). Use in the home setting is not medically necessary.

See Artificial Larynx

Elevators

Not covered

Not primarily medical in nature.

Emesis Basin

Not covered

Not primarily medical in nature.

Enuresis Training Item (penile clamp)

Prosthetic

For members with urinary incontinence.

Esophageal Dilator

Not covered

Physician instrument, not appropriate for home use

Exercise Equipment (e.g., barbells, all types of bicycles)

Not covered

Not primarily medical in nature.

Oxygen

DME

Covered if member is on oxygen

Surgical

Not covered

Face Masks

Non-reusable disposable items

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM Facial Prosthesis

COVERAGE Prosthetic

Fluidic Breathing Assister Flutter Device

Facial prostheses ARE recommended for patients with loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect See IPPB machines

DME

Foot Cradle Foot Orthotics

COMMENTS

For mobilizing secretions for members with cystic fibrosis. See Bed Cradle

Corrective For diabetics only when criteria are met; See Shoes and Foot Orthotics policy Appliances/Orthotics

Formula (enteral feedings)

Coverage criteria apply. See Nutritional Therapy: Enteral policy. Also see Home Health Care and Home Visits policy. Also see Pumps.

Gait Belt

Not covered

Gait Trainers Grab Bars (for bath and toilet)

Used gait training activities as part of a physical therapy program and billed as part of PT; reusable item. See Walkers

Not covered

Not primarily medical in nature

Gradient Pressure Stockings (e.g., Jobst stockings)

See Stockings

Hearing Aid

See Hearing Screening and Hearing Aids policy

Heat Lamp

Not covered

Not primarily medical in nature.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Heater (portable)

Not covered

Not primarily medical in nature

Heating and Cooling Plants

Not covered

Not primarily medical in nature.

Helmets (Cranial Orthosis)

Corrective Appliance/Orthotic

Helmets (Safety Equipment)

Not covered

For members with head injury or reconstructive cranial plating. Not intended for recreational purposes. Not primarily medical in nature.

Heparin/saline flushes

DME

Covered if patient meets the homebound status and heparin flush is necessary to maintain patency of the line.

High Frequency Chest Wall Compression Devices (e.g., ThAIRapy® vest)

DME

See MMG: High Frequency Chest Wall Compression Devices (click Internal, Provider Portal or Member).

Holter Monitor (cardiac event monitor) Home Prothrombin Time International Normalized Ratio (INR) Monitoring)

Note: The benefit coverage for this item is effective for services on or after 11/30/04.

Medical Supply* DME

When part of a cardiac evaluation Covered for anticoagulation management for patients on warfarin anticoagulation therapy: INR monitoring is for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets all of the following coverage criteria, and under the direction of a physician 1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and, 2. The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and 3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and, 4. Self-testing with the device should not occur more frequently than once a week.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Market: UnitedHealthcare of Oklahoma, Inc.

ITEM Humidifier

For use with C-PAP or BiPAP (heated or non-heated)

COVERAGE DME

For use with Respiratory Assist Devices For use with Oxygen System Room or Central Heating System Types

DME Not covered

Incontinence Pads Infusion Pump

Not covered

Insulin pump, including insulin and necessary supplies

Not primarily medical in nature. See Knee Orthosis.

Prosthetic Not covered DME

Inhalation Machine Injectors, Jet pressure powered injectors

Environmental control equipment; not medical in nature. See Lifts

Immobilizer (extremity) Incontinence Control Devices (mechanical and hydraulic)

For coverage criteria for C-PAP or BiPAP, see Sleep Apnea policy. For coverage criteria for Respiratory Assist Devices, see Respiratory Assist Devices.

Hydraulic Lifts Hypothermic Blankets

COMMENTS

For members with permanent anatomic and neurologic dysfunction of the bladder; see Incontinence Control (Adult) policy Non-reusable disposable items. See Pumps See Nebulizers, or Humidifiers, or IPP Machines

Not covered

DME

Alternative (e.g. routine syringes) available with the same outcome. See Diabetic Management, Services and Supplies policy Criteria apply; see Diabetic Management, Services and Supplies policy

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM IPPB Machines

COVERAGE DME

Jacuzzi

Not covered

Knee Orthosis (e.g., knee immobilizer, range of motion knee orthosis, rigid ace design knee orthosis)

Corrective Appliance/Orthotic

Lambs Wool Pads/Sheep Skins

COMMENTS When breathing is severely impaired (includes fluidic breathing assisters) Not primarily medical in nature Custom molded covered when member cannot be fitted with prefabricated immobilizer. See Alternating Pressure Pads

Leotard (pressure garment)

Not covered

Not primarily medical in nature. Therefore does not meet definition of DME

Lifts

Bathtub or Toilet

Not covered

Not primarily medical in nature. Therefore does not meet definition of DME

Hydraulic (Hoyer)

DME

Motorized (electric), Ceiling Modified Seat Lift Mechanism

Covered if transfer between bed and a chair, wheelchair, or commode requires assistance of more than one person and, without the use of a lift, the patient would be bed-confined.

Not covered DME

A seat lift mechanism is covered if all of the following criteria are met: 1) For patients with severe arthritis of the hip or knee, muscular dystrophy, or other neuromuscular diseases 2) Must be part of physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the member's condition 3) Must be completely incapable of standing up from a regular armchair or any chair in the home 4) Once standing, member must have the ability to ambulate

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS Notes: • •

Coverage is limited to the seat lift mechanism and installation of the mechanism only. Other related items and services such as costs for the chair or chair upholstery are not covered. Lift mechanism which operates by spring release with a sudden, catapultlike motion and jolts the patient from a seated to a standing position is not covered.

For Wheelchairs/Scooters/POVs

Not covered

Not primarily medical in nature

Trunk/Vehicle Modification

Not covered

Not primarily medical in nature

Not covered

Not primarily medical in nature. For the treatment of psoriasis, see Ultraviolet Cabinet.

Light Therapy Box (Therapeutic Light Box)

Lumbar-sacral (LSO)

Corrective Appliance/Orthotic

Lymphedema Pumps (segmental and nonsegmental)

Coverage criteria apply; See Pneumatic Compression Devices. DME

Lymphedema Sleeve

See Spinal Orthosis; also see Scoliosis Orthosis

Prosthetic DME

Note: CDP is considered a medical treatment rather than part of rehabilitation/therapy, therefore, CDP is not subject to rehabilitation/therapy copayment nor benefit maximum. Covered as prosthetic for intractable edema of extremity. Also covered in conjunction with lymphedema pump as DME. Coverage criteria apply. Note: CDP is considered a medical treatment rather than part of rehabilitation/therapy, therefore, CDP is not subject to rehabilitation/therapy

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS copayment nor benefit maximum.

Mandibular Device (for sleep apnea)

Massage Devices

DME

Not covered

Mattress

Not primarily medical in nature See Beds

Mobile Stander Nebulizers and Supplies

Covered when medical criteria are met. See MMG: Non-Surgical Treatment of Obstructive Sleep Apnea. Also see Sleep Apnea policy

Not covered

Not primarily medical in nature

Small volume, electric

DME

Covered for medications approved for delivery by a nebulizer, including nebulized medications for asthma.

Large Volume, Non-Disposable

DME

When medically necessary to deliver humidity to a member with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent. Not covered when used predominantly to provide room humidification.

Large Volume, Disposable

Not covered

Acceptable alternative available. Not primarily medical in nature. Disposable items are not considered DME by definition.

Ultrasonic

Not covered

Offers no proven clinical advantage over a standard nebulizer.

Portable (AC/DC)

Medication

Medical Necessity applies.

Only one nebulizer is allowed for in home use. (Stationary/Portable). Nebulizers are not allowed for out of home use as it does not meet definition of DME. Covered through the member’s supplemental pharmacy benefit

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Negative Pressure Wound Therapy Pump

See Vacuum Assisted Closure Device

Neuromuscular Electrical Stimulator (NMES)

See Electrical Stimulation Devices

Noncontact Normothermic Wound Therapy

Nutritional Therapy

Not covered

Enteral

Parenteral

See Nutritional Therapy: Enteral and Nutritional Therapy: Parenteral policies. Also see Home Health Care and Home Visits policy. DME Prosthetic

Obturator, palatal

Orthopedic Shoes

Also see Pumps. Only for surgically acquired deformity or trauma. Used to replace or fill in a missing palate or portion of the palate. Includes the denture when the denture or a portion of denture is an integral part (built-in) of the obturator. See Shoes

Ostomy Supplies

Oxygen equipment and necessary accessories

Insufficient scientific or clinical evidence to be considered reasonable and necessary.

Prosthetic

Includes irrigation/flushing equipment and other supplies directly related to care of the member's ostomy; see Ostomy Supplies policy

Stationary

DME

Medical criteria apply; documentation required.

Portable (Regulated) (e.g., Oxylite, includes conserver and tank)

DME

Medical criteria apply; documentation required.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Portable (Preset)

Not covered

First aid or precautionary equipment; essentially not therapeutic in nature. Inappropriate for home use. Does not meet the definition of DME.

Spare tanks

Not covered

Considered a convenience item.

Routine maintenance oxygen therapy, equipment and supplies outside the service area (Note: This includes travel oxygen during airline trips and cruises)

Not covered

EOC Exclusion

Pacemaker Monitors (self-contained) • Audible or Visible Signal • Digital Electronic

DME

Member must have cardiac pacemaker; see Cardiac Pacemakers and Defibrillators policy

Paraffin Bath Unit

Portable

DME

Covered when the patient has undergone a successful trial period of paraffin therapy ordered by a physician and the patient’s condition is expected to be relieved by a long term use of this modality

Standard

Not covered

Not appropriate for home use

Not covered

Support exercise equipment. Primarily for institutional use.

Parallel Bars Peak Flow Meter, hand-held

Percussor (Non-Vest type)

DME Electric or pneumatic, home model

DME

For the self-monitoring of patients with pure asthma when used as part of a comprehensive asthma management program Covered for mobilizing respiratory tract secretions in patients with chronic obstructive lung disease, chronic bronchitis or emphysema, when patient or operator of powered percussor has received appropriate training by a physician or

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS therapist, and no one competent to administer manual therapy is available. For ThAIRapy® Vest System, see High Frequency Chest Wall Compression Devices)

Intrapulmonary Percussive Ventilator (IPV) Personal or Comfort Items Pessary Pneumatic Compression Devices

Not covered

No data to support the effectiveness of the device in the home setting. Inappropriate for home use. Therefore does not meet the definition of DME.

Not covered

Not primarily medical in nature

Medical Supply* DME

For prolapse of the uterus or nonsurgical treatment of rectocele and cystocele Pneumatic compression devices consist of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Pneumatic Compression Devices ARE recommended for the following indications: 1.

2.

Lymphedema – for the treatment of lymphedema in the home setting if the patient has undergone a 4-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise and elevation of the limb. The garment may be prefabricated or customfabricated but must provide adequate graduated compression Chronic venous insufficiency (CVI)*

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Market: UnitedHealthcare of Oklahoma, Inc.

ITEM Shoes

COVERAGE

Inserts/Orthotics

Corrective Appliance/Orthotic

Orthopedic

Corrective Appliance/Orthotic

Prosthetic

Prosthetic

Therapeutic (e.g., diabetic shoes)

Sitz Bath (portable)

Spinal Orthosis

DME

Splints

Cervical-thoracic-lumbar-sacral (CTLSO)

Corrective Appliance/Orthotic

Lumbar-sacral (LSO)

Corrective Appliance/Orthotic

Bi-directional static progressive stretch splinting (e.g., JAS splints, ERMI

Part of a treatment plan for perineal infection/injury See Mandibular Device

Medical Supply*

Thoracic-lumbar-sacral (TLSO)

See Shoes and Foot Orthotics policy

Corrective Appliance/Orthotic

Sleep Apnea Device Slings

COMMENTS

Used to support and limit motion of an injured upper arm Covered when ordered by physician to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury or surgical procedure on the spine or related soft tissues, or to otherwise support weak spinal muscles and/or a deformed spine. Also see Scoliosis Orthosis.

Corrective Appliance/Orthotic Not covered

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS Pneumatic compression devices must be prescribed by a physician and used with appropriate physician oversight (i.e., physician evaluation of the patient’s condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment). The determination by the physician of the medical necessity of a pneumatic compression device must include all of the following: 5. The patient’s diagnosis and prognosis 6. Symptoms and objective findings, including measurements which establish the severity of the condition 7. The reason the device is required, including the treatments which have been tried and failed 8. The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home A segmented, calibrated gradient pneumatic compression device is recommended only when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber. * Chronic Venous Insufficiency (CVI): CVI of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis,

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS chronic edema and venous ulcers.

Pneumatic Splints Porcine (Pig) Skin Dressings

Postural Drainage Boards

See Ankle Foot Orthosis (AFO)/Knee-Ankle-Foot Orthosis (KAFO) Medical Supply*

DME

When used as an airtight (occlusive) dressing for burns, donor sites, bedsores (decubiti), and ulcers/wounds For members with chronic pulmonary condition Recommended if patient meets Mobility Assistive Equipment clinical criteria. Refer to Mobility Assistive Equipment Clinical Criteria

Power Operated Vehicles (POV)/Scooters

Also see Wheelchairs and Accessories policy See Traction.

Power traction equipment/devices (e.g., VAX-D®, DRX9000, SpineMED™, Spina System™, Lordex® Decompression Unit, DRS System™) Pulse Oximeter

DME

A pulse oximeter is covered in the home to monitor oxygen saturation when medically necessary for the safe management of a medical diagnosis that would otherwise require treatment at a higher level of care. Coverage requires that an individual be available in the home with the requisite training to interpret and apply pulse oximetry data. Medical conditions that may warrant a home pulse oximeter include, but are not limited to: •

infants with severe chronic lung disease, such as bronchopulmonary dysplasia • premature infants being actively monitored for apnea • members who require mechanical home ventilation • members being weaned off of a home ventilator or oxygen therapy *Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS • • •

members with a tracheostomy who require tracheal suctioning to manage pulmonary secretions members with a severe cardiopulmonary diagnosis that requires immediate adjustment of oxygen flow rates members with a progressive neuromuscular condition that impairs the muscles of respiration (e.g., ALS, Muscular Dystrophy, Myasthenia Gravis)

The use of a home pulse oximeter to monitor oxygen saturations in COPD or Asthma is not considered medically necessary in the absence of special circumstances such as those outlined above. Pumps, including medications and necessary supplies

Enteral

See Diabetic Management, Services and Supplies and Nutritional Therapy: Enteral policies. Pumps, tubing and supplies necessary to deliver the enteral formula is covered when gravity or syringe is not appropriate, e.g. premature infant.

Infusion

DME

Implantable Infusion Pumps ARE recommended for the following: 1. Chemotherapy – intra-arterial infusion of 5-FudR for the treatment of liver cancer for patients with primary hepatocellular carcinoma or Duke’s Class D colorectal cancer, in cases where metastases are limited to the liver and the disease is not resectable or the patient refuses surgery to remove the tumor 2 Treatment of severe spasticity – intrathecal pump implantation is indicated for spasticity when ALL of the following are present: a. Cerebral origin (e.g., stroke, cerebral palsy) or spinal cord origin, or reflex sympathetic dystrophy AND ANY ONE of the following: 1) Severe painful joint spasticity

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

3

2) Spasticity that prevents adequate performance of activities of daily living (ADL) or mobility 3) Spasticity that prevents adequate care and hygiene 4) Spasticity that places patient at increased risk for contracture, pressure sores, or other complications b. Symptoms poorly controlled with maximal medical therapy or patient unable to tolerate medications c. Medically stable patient d. Successful trial (i.e., >1-point drop in Ashworth scale) with epidural injection of baclofen e. Patient, family, and providers (as appropriate) are educated about important warning signs of baclofen withdrawal syndrome f. ALL of the following: 1) No known allergy or hypersensitivity to agent being infused 2) No current infection 3) No other implanted, programmable devises 4) Body size adequate to support pump device Treatment of chronic malignant pain – intrathecal pump implantation is indicated for chronic malignant pain for ALL of the following: a. Pain secondary to malignancy, generally in patient with >3 months life expectancy b. Failure of, or unacceptable side effects from, conventional oral and subcutaneous opioids c. Patient has undergone psychologic screening d. Preliminary intrathecal injection confirms that analgesia, side effects, and overall patient acceptability appear adequate e. Patient has undergone evaluation and treatment by pain specialist, if available

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS f.

4.

ALL of the following: 1) No known allergy or hypersensitivity to agent being infused 2) No current infection 3) No other implanted, programmable devises 4) Body size adequate to support pump device Other uses – if the patient’s physician verifies ALL of the following: a. The drug is reasonable and necessary for the treatment of the individual patient’s condition b. It is medically necessary that the drug be administered by an implanted infusion pump c. The FDA-approved labeling for the pump specifies that the drug being administered and the purpose for which it is being administered is an indicated use of the pump

External infusion pumps for vancomycin are not covered. (Note: There is insufficient evidence to support the necessity of using an external infusion pump, instead of a disposable elastomeric pump or the gravity drip method, to administer vancomycin in a safe and appropriate manner) Implantable infusion pumps for infusion of heparin in the treatment of recurrent thromboembolic disease are not covered. Insulin, external Insulin, implantable

DME

Coverage criteria apply; See Diabetic Management, Services and Supplies policy.

Not covered

Lymphedema

DME

Pain Control

DME

Treatment of chronic malignant pain – intrathecal pump implantation is indicated for chronic malignant pain for ALL of the following:

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 1. Pain secondary to malignancy, generally in patient with >3 months life expectancy 2. Failure of, or unacceptable side effects from, conventional oral and subcutaneous opioids 3. Patient has undergone psychologic screening 4. Preliminary intrathecal injection confirms that analgesia, side effects, and overall patient acceptability appear adequate 5. Patient has undergone evaluation and treatment by pain specialist, if available 6. ALL of the following: 5) No known allergy or hypersensitivity to agent being infused 6) No current infection 7) No other implanted, programmable devises 8) Body size adequate to support pump device

Parenteral

DME

External infusion pumps ARE recommended if EITHER of the following sets of criteria (a) or (b) are met: a. 1. Parenteral administration of the drug in the home is reasonable and necessary 2. An infusion pump is necessary to safely administer the drug 3. The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy 4. The therapeutic regimen is proven or generally accepted to have significant advantages over intermittent bolus administration regimens or infusions lasting less than 8 hours b. 1. Parenteral administration of the drug in the home is reasonable and necessary 2. An infusion pump is necessary to safely administer the drug 3. The drug is administered by intermittent infusion (each episode of

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

Market: UnitedHealthcare of Oklahoma, Inc.

ITEM

COVERAGE

COMMENTS infusion lasting less than 8 hours) which does not require the patient to return to the physician's office prior to the beginning of each infusion 4. Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information See also Diabetic Management, Services and Supplies and Parenteral Nutritional Therapy policies.

For Erectile Dysfunction Punctal Plug Ramp (wheelchair)

See Vacuum Pump Medical Supply* Not covered

For treatment of dry eyes Not primarily medical in nature

Recliner (chair)

DME

Member must be on home dialysis

Respiratory Assist Devices

DME

Coverage criteria apply; See Humidifier. Also see Sleep Apnea policy

Rib Belt

Corrective Appliance/Orthotic

Covered when all of the following criteria are met: 1) Serves a medical purpose and it is only associated with treating an illness, injury or malformed body member; 2) Provides support and counter force (a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that is being used to brace; 3) Not used to supply compression therapy (e.g. to reduce size, volume, or swelling of a body member or to help circulation)

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS 4) Not used for convenience or appearance 5) Not used for cosmetic purposes

Rolling Chair (Geri Chair)

DME

Safety Rollers

See Walkers

Sauna Baths Scoliosis orthosis

Coverage is limited to those roll-about chairs having casters of at least 5 inches in diameter and officially designed to meet the needs of ill, injured, or otherwise impaired individuals. Covered if determined that the patient’s condition is such that there is a medical need for this item and it has been prescribed by the patient’s physician in lieu of a wheelchair.

Not covered Body Jacket Cervical Thoracic Lumbar Sacral Orthosis (CTLSO) Thoracic-lumbar-sacral orthosis (TLSO)

Corrective Appliance/Orthotic

Not primarily medical in nature. General indications for orthotic treatment in idiopathic scoliosis are as follows: 1. Skeletally immature patients, prior to Risser grade 5 (usually one year post menarche in girls) 2. Children presenting with curvature of 20 to 30 degrees should also be observed, at least initially. During the observation period, roentgenograms should be obtained at 3 to 6 month intervals and compared with the original films. If the curvature increases by more than 5 degrees in a skeletally immature patient, bracing is recommended 3. Children presenting with 25 degrees to 39 degrees curvature require prompt treatment. These patients are at high risk of progression of curvature 4. Boys with progressive curvature in excess of 25 degrees, including those presenting at Risser grade 4 5. Patients with Scheuermann’s Kyphosis including kyphosis of more than 50 degrees. To maintain correction, the brace should be worn until there

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS is improvement in vertebral wedging to roughly 5 degrees. Bracing for longer than 18 months may be necessary to achieve this improvement Note: In very young patients, bracing may retard progression long enough to allow further trunk growth before the inevitable fusion. Once curvature exceeds 40 degrees, surgical treatment may be the only means of controlling and correcting the deformity. Immediate bracing IS recommended for the following to allow significant trunk growth prior to surgical intervention: 1. Skeletally immature patients (at Risser grades 0 to 2) presenting with 30 to 40 degrees curvature 2. Flaccid paralysis and 20 degrees or more of curvature Note: Risser grades are based on the degree of bony fusion of the iliac apophysis, from grade 0 (no ossification) to grade 5 (complete bony fusion) (Reamy and Slakey, 2001). Note: The recommended duration of bracing varies from 16 hours/day to 23 hours/day. Also see Spinal Orthosis.

Shower/Bath Tub Seat

Not covered

Not primarily medical in nature.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

system ) Dental Splint (prefabricated, off-theshelf bite guard; aka night guard appliance)

Not Covered

Dental splint is an off-the-shelf intraoral device that does not require professional fitting or adjustment and is used to prevent damage to teeth caused by bruxism. (Note: Dental splint does not include oral splints for the treatment of TMJ that require custom fitting and adjustment by a licensed healthcare professional.)

Dynamic (e.g., Dyna Splint)

DME

Foot (e.g., Dennis-Browne)

Corrective Appliance/Orthotic

Used as splint/brace to correct rotational anomalies of lower legs; worn during sleep

Occlusal Splint (custom fabricated bite plate for TMJ)

Corrective Appliance/Orthotic

Custom made occlusal splints are removable intraoral appliances fabricated and fitted by a licensed healthcare professional to be worn at night for the treatment of painful temporomandibular joint disease.

Covered when used to reduce joint contractures

Refer to the MMG: Mandibular Disorders (click Internal, Provider Portal or Member) for coverage criteria for the treatment of TMJ Disorders. For Sleep Apnea device, see Mandibular Device Wrist/Hand/Finger

Stockings

Gradient Compression Stockings (e.g. Jobst stockings)

Corrective Appliance/Orthotic

Prosthetic

For mild sprains, strains and carpal tunnel conditions. Custom molded covered only when member cannot be fitted with the prefabricated wrist/hand/finger/splint/brace. Covered when medical criteria are met. Note: Coverage is limited to initial 2 pairs of hosiery and replacement of 2 pairs every six month if Covered Person is compliant in wearing the hosiery.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

Support Hose (e.g., Ted Hose)

Not covered

Non-reusable, non-rental item

Surgical Stockings

Not covered

Non-reusable, non-rental item

Stump Socks

See Artificial Limb.

Suction Pump or Machine

Surgical Boot

Syringes

COMMENTS

DME

Corrective Appliance/Orthotic Bulb, Ear Hypodermic

Not covered

Covered for members who have difficulty raising and clearing secretions secondary to one of the following: 1) Cancer or surgery of the throat or mouth 2) Dysfunction of the swallowing muscles 3) Unconsciousness or obtunded state 4) Tracheostomy. Must be appropriate for use without professional supervision. Also known as ambulatory boot

Non re-usable, not rental item

Medical Supply*

Telephone Alert System

Not covered

Not primarily medical in nature

Telephone Arms/Cradle

Not covered

Not primarily medical in nature

TENS Unit/Muscle Stimulator

See Electrical Stimulation Devices for Chronic Pain

ThAIRapy® Vest System

See High Frequency Chest Wall Compression Devices

Thoracic Lumbar Sacral Orthoses (TLSO)

See Spinal Orthosis; also see Scoliosis Orthosis

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM Tinnitus Masker

COVERAGE Not covered

TMJ Device Prosthetic

Toilet Seat, Elevated Bidet

Traction Equipment

Effectiveness not adequately proven. See Splints - Occlusal Splint

Toe Filler

Tracheostomy

COMMENTS

Not covered

See Shoes and Foot Orthotics policy Not primarily medical in nature, not medical equipment.

Speaking Valve and Tubes

Prosthetic

A trachea tube has been determined to satisfy the definition of a prosthetic device, and the tracheostomy speaking valve is an add on to the trachea tube which may be considered a medically necessary accessory that enhances the function of the tube, which makes the system a better prosthesis. As such, a tracheostomy speaking valve is covered as an element of the trachea tube which makes the tube more effective.

Care Kit (Initial and Replacements)

Prosthetic

A tracheostomy care kit is covered for a member following an open surgical tracheostomy which has been open or is expected to remain open for at least 3 months. Replacement kits are covered at one per day only.

Cervical (Over-the-Door or Cervical Portable Traction Unit)

DME

Covered if both the following criteria are met 1. The patient has a musculoskeletal or neurologic impairment requiring traction equipment; and, 2. The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.

Cervical, attached to headboard

Not covered

No proven clinical advantage compared to over-the-door traction mechanism

Freestanding Traction Stand

Not covered

No proven clinical advantage compared to over-the-door traction mechanism

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

COVERAGE

COMMENTS

Pneumatic Free-standing Cervical, Stand/Frame (e.g. Saunders HomeTrac)

DME

Covered if member meets criteria for over-the-door traction unit and one of the following 3 criterion are met: 1. The treating physician orders greater than 20 pounds of cervical traction in the home setting; or, 2. The Member has: a. a diagnosis of temporomandibular joint (TMJ) dysfunction; and b. received treatment for the TMJ condition; or, 3. The Member has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be utilized. Refer to Medical Management Guidelines: Home Traction Therapy click Internal, Provider Portal or Member).

Power traction equipment/devices (e.g., VAX-D®, DRX9000, SpineMED™, AccuSpina System™, Lordex® Decompression Unit, DRS System™)

Not Covered

The use of a spinal unloading device is unproven for the treatment of low back pain due to inadequate clinical evidence of safety and/or efficacy in published peer-reviewed medical literature. Refer to Medical Management Guidelines: Home Traction Therapy click Internal, Provider Portal or Member).

Spinal Unloading Devices (includes spinal and axial decompression units, pneumatic vests)

Not Covered

The use of a spinal unloading device is unproven for the treatment of low back pain due to inadequate clinical evidence of safety and/or efficacy in published peer-reviewed medical literature.

ITEM

Weights, bags Transfer (Sliding) Board Trapeze Bar

DME Not covered DME

When used in conjunction with traction Not primarily medical in nature. A trapeze bar attached to a bed is covered if the patient has a covered hospital bed and the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. Not

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS covered when used on an ordinary bed. A "Free standing" trapeze equipment is covered if the patient does not have a covered hospital bed but the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed

Treadmill Exerciser Truss Ultraviolet Cabinet

Not covered Prosthetic DME

Exercise equipment, not primarily medical in nature Covered as prosthetic when used as a holder for surgical dressings or for lumbar strains, sprains or hernia. Coverage criteria apply; see MMG: Laser Therapy for Cutaneous Vascular Lesions and Pilonidal disease (click Internal, Provider Portal or Member). Generally used to treat chronic ulcers that are usually caused by varicosities of the leg

Unna Boot/Strapping

Medical Supply*

Urinal (autoclavable)

DME

If member is confined to bed.

Vacuum Assisted Closure Device (VAC) or Negative Pressure Wound Therapy Pump

DME

Covered for wound treatment when criteria are met.

Vacuum Pump or Device (e.g., ErecAid)

Not covered

Some members may have coverage as DME. Refer to Section B of the Sexual Dysfunction policy.

Vaporizers

Not covered

Not primarily medical in nature.

Vehicle/Trunk Modifications

Not covered

Not primarily medical in nature.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

COVERAGE

COMMENTS

Ventilators (including supplies)

DME

Ventilators (respirators) are recommended for the treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. This recommendation includes both positive and negative pressure types.

Vitrectomy Face Support

DME

Effective 6/24/05, vitrectomy face down support is covered as prescribed by the participating/contracting provider for post-vitrectomy surgery (e.g., repair of macular hole, retinal detachment) when face-down positioning may be required for several weeks to maximize retinal tamponade and subsequently, macular hole closure or retinal attachment.

ITEM

•

Not covered for post-cataract surgery

•

Rental only

•

Beds, chairs and other accessories (e.g., seated support, crescent pad, 2way mirror, arm rest, cushions) are not covered.

Note: Prior to 6/24/05, vitrectomy face support was not covered on the basis that alternatives (e.g., pillow positioning) are available with the same outcome. Walkers (standard)

Rigid (pick-up), adjustable or fixed height

DME

Folding (pick-up), adjustable or fixed height

DME

Rigid, wheeled, without seat

DME

Folding, wheeled, without

DME

Covered when 1) member has a medical condition impairing ambulation and there is a potential for ambulation; and 2) there is a need for greater stability and security than provided by a cane or crutches. Baskets are not covered.

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

seat Walkers (special types)

Heavy duty, multiple braking system, variable wheel resistance (Safety Rollers)

DME

Covered for members who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand.

Heavy duty

DME

Covered for members who meet the coverage criteria for a standard walker and who weigh more than 300 pounds.

Leg extensions

DME

Covered only for members 6 feet tall or more.

With Seat

DME

If medically necessary

With basket

Wedge Pillow Wheelchairs and Accessories

Not Covered

Additional accessories to DME, corrective appliances or prosthetics which are primarily for the comfort or convenience of the member are not covered.

Not covered

Non re-usable item, non-rental.

DME

Recommended if patient meets Mobility Assistive Equipment clinical criteria. Refer to Mobility Assistive Equipment Clinical Criteria Also see Wheelchairs and Accessories policy

Whirlpool Bath Equipment (standard)

DME

Medical necessity is determined by the following: 1. Evidence that a whirlpool bath offers substantial therapeutic benefit for the patient’s medical condition 2. Verification that the patient is homebound or that treatment in the home is the least costly alternative

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 3/21/02, 6/20/02, 12/05/02, 03/20/03, 05/06/03, 06/18/03, 1/14/04, 3/17/04, 6/23/04, 8/31/04, 11/18/04, 2/2/05, 5/19/05, 7/21/05, 5/4/06, 8/17/06, 12/7/06, 1/24/07, 5/10/07, 5/17/07, 8/28/07, 11/6/07, 5/06/08, 5/22/08, 06/25/08, 9/25/08, 12/16/08, 4/15/09, 6/23/09, 7/16/09, 12/16/09, 4/21/10, 6/22/10, 11/15/10, 4/19/11, 6/21/11, 7/15/11, 12/20/11, 09/17/12, 10/25/12, 12/17/12, 12/28/12, 7/01/13

ITEM

COVERAGE

COMMENTS

Whirlpool Pump (portable)

Not covered

Not primarily medical in nature

Wig/Hairpiece (cranial prosthesis)

Not covered

Not primarily medical in nature Note: The following applies only for Employer Groups with 51+ employees: Some Members may have coverage for wigs under the DME benefit. Members must be receiving chemotherapy and/or radiation therapy and must obtain a prescription from their PCP or oncologist. Members must purchase wig/toupee and will be reimbursed up to $150. One wig/toupee per year is covered. Refer to the Covered Person’s Policy, Certificate or SOB for coverage eligibility.

Wrist splint

See Splints

*Medical Supplies are covered only when they are incident to a physician's professional services or authorized home health services and are furnished as an integral, although incidental, part of those services in the course of diagnosis or treatment of an injury or illness.

SignatureValue™ Benefit Interpretation Policy SUBJECT:

EDUCATION

TITLE:

Educational Programs for Members

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 5/6/03, 5/19/05, 8/17/06, 7/16/08, 6/23/09, 6/22/10, 6/21/11, 8/16/11, 06/28/12, 6/27/13

Policy Number: E-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

UnitedHealthcare offers educational health improvement programs which may be available to members. Contact the Member Services Department to determine program details and availability and member eligibility.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Member education programs furnished by providers of services (e.g., hospitals, outpatient settings, skilled nursing facilities, etc.) to the extent that the programs are appropriate and reasonable and medically necessary for the treatment and/or management of a member’s illness or injury. The frequency of the health education services must be medically reasonable to the goals of the program (see Medical Necessity and Rehabilitation: Medical - Physical, Occupational and Speech Therapy policies). Examples include, but are not limited to: a. Teaching the member or caregiver how to: 1) Administer injections 2) Follow a prescribed diet 3) Administer colostomy care

2.

3.

D.

NOT COVERED 1. 2.

E.

Health education services not closely related to the care and treatment of the member Examples include, but are not limited to: a. Programs directed toward instructing members or the general public in preventive health care activities b. Programs designed to prevent illness by instructing the general public in: 1) General nutritional habits 2) General exercise regimens 3) General hygiene and personal care

DEFINITIONS 1.

F.

4) Administer medical gases (e.g., oxygen) 5) Carry out a maintenance program designed by a physical therapist (PT) b. Instruction by an occupational therapist (OT) on techniques to improve the member’s level of independence in their activities of daily living (ADLs) (see Rehabilitation: Medical - Physical, Occupational and Speech Therapy policy) Nutritional counseling by a licensed nutritionist or dietician, necessary as part of the treatment protocol for medical conditions (e.g., hyperlipidemia, PKU) when the member’s PCP is unable to provide the necessary nutritional counseling or the initial nutritional counseling by PCP has failed. Note: Nutritional counseling is not covered for the purpose of weight alteration except when provided by the member’s PCP. See Weight Gain or Weight Loss Programs and Treatment of Morbid Obesity policies. For Wellness Program, refer to UnitedHealthcare’s Preventive Medical Management Guidelines unless there is a state mandate. See Medical Management Guideline: Preventive Care Services (click Internal, Provider Portal or Member).

Health Education Services: Educational programs that include educational counseling, classes and materials and are provided by the physician or designee.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

EMERGENCY AND URGENT SERVICES

TITLE:

Emergency and Urgent Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 9/19/02, 1/14/04, 5/4/06, 5/22/08, 4/15/09, 10/21/09, 6/22/10, 4/19/11, 04/26/12, 04/25/13, 10/01/13

Policy Number: E-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

42 Code of Federal regulations(CFR) §489.24 Emergency Medical Treatment and Active Labor Act (EMTALA) (Full text available @http://www.gpoaccess.gov/cfr/retrieve.html) "All hospitals, regardless of contractual relationship, must provide for an appropriate medical screening exam (MSE). The hospital’s emergency room department is required to determine whether an emergency medical condition exists or whether the member is in active labor. The hospital may not delay the examination or treatment in order to inquire into the member’s method of payment or insurance status. This law was enacted due to complaints that hospitals were refusing to treat indigent patients in their emergency rooms and referring (dumping) them to county facilities for care. If an emergency medical condition exists (e.g., if the member’s health is in serious jeopardy o if there is a reasonable likelihood of serious impairment to bodily functions or of serious dysfunction of any bodily organ or part) or if a pregnant woman is in labor, the hospital must either: (1) Provide further medical examination and treatment as may be required to stabilize the member’s medical condition or provide for treatment of the labor, or (2) Transfer the individual to another medical facility if such a transfer is appropriate. If the member refuses to be treated or does not consent to an appropriate transfer, the hospital will be deemed to have met its obligations under its provider agreement. [SSA 1867(b)]. The transfer of an emergency room patient who has not been properly treated, as described above is not appropriate unless the member (or a person acting in his behalf) requests a transfer or a physician has certified that the medical benefits to be obtained from appropriate medical treatment outweigh the risks of transfer and the receiving hospital must agree to accept the member, and it must be provided with all relevant medical records from the transferring hospital. Participating hospitals with specialized facilities cannot refuse to accept a member who needs those facilities. The transfer must be effectuated by qualified personnel using appropriately equipped transportation. [SSA 1867(c)]."

2.

Oklahoma Department of Insurance, Title 36 Section 6907 (L): Emergency Services:

Based on patient’s presenting symptoms, arising from any injury, illness, or condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable and prudent layperson could reasonably expect the absence of immediate medical attention to result in: a. Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child. b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part. B.

STATE MARKET PLAN ENHANCEMENTS 1.

2.

C.

“Medically necessary emergency services” means health care services that are provided to an insured person by a provider of health care after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in: a. Serious jeopardy to the health of an insured b. Serious jeopardy to the health of an unborn child c. Serious impairment of a bodily function d. Serious dysfunction of any bodily organ or part "Urgently needed services" are services provided outside the geographic service area by non contracting Medical Providers or Facilities. They are covered services that appear to be required in order to prevent serious deterioration of the member's health resulting from an illness or injury if: a. The member is temporarily absent (less than 90 days) from the geographic service area b. Receipt of the health care service cannot be delayed until the member returns to the geographic service area.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

Note: Also refer to the Emergency Health Services and Urgent Care Center Services Medical Management Guideline (click Internal, Provider Portal or Member). Emergency services and urgently needed services when the member is in his or her service area (Note: see sections A and B above for market-specific definitions of Emergency Services and Urgent Services) Coverage of emergency services and urgently needed services, transportation, and patient management when the member is out-of-area will be based on the following (Note: see sections A and B above for market-specific definitions of Emergency Services and Urgent Services): A. Emergency/urgently needed services 1. Requested services are medically necessary 2. Requested services are considered covered benefits by UnitedHealthcare 3. Requested services are necessary to enable the member to return to the service area, or to prevent serious deterioration of the member’s condition 4. For members who are hospitalized, determine a coordination plan. The treating physician must be in agreement with the Plan’s proposed coordination plan before the member is clinically stable to return to the Service Area. If not, a contracting/participating physician, ideally with privileges at the facility, will assume care of that member and authorize transfer of the member back to the service area. If not, the Plan must attempt to reach an

B.

C.

D.

NOT COVERED 1.

E.

Services that do not qualify as urgent or emergent as defined in Section A and/or B above

DEFINITIONS 1. 2.

F.

agreement with the treating physician concerning appropriateness of discharge or transfer for the member. Until such agreement is reached, the Plan, in the majority of cases, may be financially responsible for such services until an agreement is reached Transportation 1. Determine transportation method for member transfer. A consensus among the treating physician, the PCP or Plan specialist, and the Plan’s Medical Director is required regarding the member’s medical stability for transfer and the proposed transportation method Patient Management Management of the patient should be based on the following: 1. Post-stabilization care cannot be limited except when there is a contracting/participating physician who will assume appropriate care of the member who remains out-of-area 2. All medically necessary covered benefits requested and ordered by the treating physician are covered without distinction that the member is out-of-area 3. Denial of coverage may be issued if: a. The care or services requested are not a Plan covered benefit b. The services were not medically necessary c. Services could await the member’s return to the service area without putting the member in danger of serious deterioration or bodily functional loss d. The treating physician is in agreement with the transfer; there is a physician willing to accept the member’s care, but the member refuses. If the member can reasonably return to the service area but the member refuses, the Plan must explain the denial of continued out-of-area coverage and give the member a written notice and a reasonable time in which to return to the service area 4. The Plan is responsible for medically necessary nurse-companion or other medical or health care services that are ordered by a treating physician and/or are a condition of the member’s discharge (At UnitedHealthcare’s discretion and if only if cost effective) 5. Return transportation to the service area if the member can return safely by common carrier, including medically necessary special accommodations that are not health services (e.g., first class airline ticket seat or two or three economy seats for the member to elevate extremity) are the responsibility of the member 6. The members’ coverage may be further mandated by the individual State laws governing basic healthcare and out-of-area coverage

See sections A and B above for market-specific definitions of Emergency and Urgent Services. Post Stabilization: medically necessary care following stabilization of an emergency medical condition.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

EXPERIMENTAL AND/OR INVESTIGATIONAL PROCEDURES, ITEMS AND TREATMENTS

TITLE:

Experimental and/or Investigational Procedures, Items and Treatments

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/31/04

Effective Date: 10/1/04

Review Date: 12/5/05, 11/6/07, 12/16/08, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: E-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A. FEDERAL/STATE MANDATED REGULATIONS 1.

None

B. STATE MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Experimental and/or investigational procedures, items and treatments may be covered a. When mandated by the state or federal law (See Section A and/or B); or b. as determined by a UnitedHealthcare Medical Director, or his/her designee (See Section E for the definition of “Experimental and/or Investigational”)

Also see Medical Necessity policy D. NOT COVERED 1.

Experimental and/or investigational procedures, items and treatment that do not meet the above coverage criteria

E. DEFINITIONS 1.

Experimental and/or Investigational: For the purposes of this policy, procedures, studies, tests, drugs or equipment will be considered experimental and/or investigational if any of the following criteria/guidelines is met: a. It is being provided pursuant to a written protocol that describes among its objectives the

b.

c.

d. e.

f. g. h.

determination of safety, efficacy, toxicity, maximum tolerated dose or effectiveness in comparison to conventional treatments. It is being delivered or should be delivered subject to approval and supervision of an institutional review board (IRB) as required and defined by federal regulations or other official actions (especially those of the FDA or DHHS). Other facilities studying substantially the same drug, device, medical treatment or procedures refer to it as experimental or as a research project, a study, an invention, a test, a trial or other words of similar effect. The predominant opinion among experts as expressed in published, authoritative medical literature is that usage should be confined to research settings. It is not experimental or investigational itself pursuant to the above criteria, but would not be medically necessary except for its use in conjunction with a drug, device or treatment that is experimental or Investigational (e.g., lab tests or imaging ordered to evaluate the effectiveness of an experimental therapy). It cannot lawfully be marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use. It is a subject of a current investigation of new drug or new device (IND) application on file with the FDA. It is the subject of an ongoing clinical trial (Phase I, II or the research arm of Phase III) as defined in regulations and other official publications issued by the FDA and Department of Health and Human Services (DHHS).

The sources of information to be relied upon by UnitedHealthcare in determining whether a particular treatment is experimental or investigational include, but are not limited to the following: a. The member's medical records; b. The protocol(s) pursuant to which the drug, device, treatment or procedure is to be delivered; c. Any informed consent document the member, or his or her representative, has executed or will be asked to execute, in order to receive the drug, device, treatment or procedure; d. The published authoritative medical and scientific literature regarding the drug, device, treatment, or procedure; e. Expert medical opinion; f. Opinions of other agencies or review organizations, e.g., ECRI Health Technology g. Assessment Information Services, HAYES New Technology Summaries or MCMC Medical Ombudsman; h. Regulations and other official actions and publications issued by agencies such as the FDA, DHHS and Agency for Health Care Policy and Research (“AHCPR”) F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

FAMILY PLANNING

TITLE:

Basic Infertility Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 9/1/00, 6/20/02, 6/18/03, 12/5/05, 5/4/06, 7/16/08, 4/15/09

Policy Number: F-R-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

OAC 365:40-5-20. Basic health care services Basic health care services shall include: (1) Physician services including consultant and referral services by a physician, and other health professional services as necessary to provide allopathic, osteopathic, chiropractic, podiatric, optometric, and psychological services. If a service of a physician may also be provided under applicable State law by another type of health professional, an HMO may provide the service through these other health professionals. (2) Outpatient services including diagnostic services, treatment services and x-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at a hospital…………………………………………………………… (8) Diagnostic laboratory and diagnostic and therapeutic radiological services in support of basic health care services. (9)Home health services provided at an enrollee's home by health care personnel, as prescribed or directed by the responsible physician or their authority designated by the HMO. (10) Preventive health services, which shall be made available to enrollees and shall include at least the following: (A) Services for children from birth to age 21 as determined by the American Academy of Pediatrics in "Guidelines for Health Supervision"; (B) Immunizations for adults and children as recommended by the Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention, except those required for foreign travel and employment; (C) Periodic health evaluations for adults to include voluntary family planning services; and (D) Preventive services identified through the HMO quality assurance program designed to contribute to achieving the U.S. Department of Health and Human Services "Healthy People 2010" objectives…………………………………………………………………….

None

COVERED BENEFITS

Notes:  Some employer groups do not have coverage for infertility services. Refer to the member’s EOC/SOB or contact the Customer Service Department to determine eligibility before using this benefit interpretation policy.  All services require prior-authorization. 1.

D.

NOT COVERED 1.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

E.

Reasonable and necessary services associated with the diagnosis and treatment of infertility a. Some examples include: 1) Medical history 2) General medical exams a) Females (1) Pelvic exam (2) Laboratory (e.g., FSH, LH, prolactin, progesterone) (3) Cultures for infectious agents (4) Hysterosalpingogram as determined appropriate by the participating treating physician b) Males (1) Semen analysis (2) Laboratory studies (e.g., FSH, LH, prolactin, serum testosterone) (3) Testicular biopsy in case of azoospermia (4) Scrotal ultrasound as determined appropriate by the participating treating physician 3) Artificial insemination (Refer to the member’s EOC/SOB for specific coverage)

Experimental and/or investigational diagnostic studies or procedures such as:  Inoculation of female with male partner's white cells  Immunoglobulin (IVIG) (See the Experimental and/or Investigational Procedures, Items and Treatments policy) Frozen embryo transfers Further infertility treatment when either or both partners refuse to participate or lack full participation in treatment plan GIFT, ZIFT, or in-vitro fertilization Infertility services for non-members (e.g., surrogate mothers who are not UnitedHealthcare members) Infertility services for post-menopausal women Infertility treatment from a previous elective vasectomy or tubal ligation Reversal of a previous elective vasectomy or tubal ligation Microdissection of the zona or sperm microinjection Ovum, ovum donor or ovum bank charges Sperm, sperm penetration, sperm donor or sperm bank charges Treatment of female sterility in which a donor ovum would be necessary (e.g., post-menopausal syndrome) Oral prescription medications such as clomid (clomiphene citrate), without supplemental pharmacy benefit Medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, anorgasmy, or hyporgasmy

DEFINITIONS

1.

2.

3.

4.

5.

6.

F.

Artificial Insemination or Intrauterine Insemination (IUI): A medical procedure by which sperm are deposited within the upper vagina and cervix or directly placed via catheter into the uterine cavity. Prior to artificial insemination, the sperm may be "washed" in order to eliminate the presence of antigens, which may be contributors to infertility in certain cases, or may cause hypersensitivity. Cycle (Menstrual cycle): The periodically recurrent series of changes occurring in the uterus and associated sex organs (ovaries, cervix and vagina) associated with menstruation and the intermenstrual period. The human cycle averages 28 days in length, measured from the beginning of menstruation. The menstrual cycle may vary in length, even in the same person from month to month. Gamete Intrafallopian Transfer (GIFT): An infertility treatment that involves obtaining eggs (through medical and surgical procedures) and sperm, loading the eggs and sperm into a catheter, then emptying the contents of the catheter into the fallopian tube. The intent of this procedure is to have fertilization occur in the fallopian tubes as it would in a fertile woman. Infertility: Infertility means either (1) the presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or (2) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular attempts to conceive. In-vitro Fertilization (IVF): A highly sophisticated infertility treatment that involves obtaining mature eggs (oocytes) by surgical or nonsurgical procedures and combining the eggs with sperm in a laboratory setting. If fertilization and cell division occur, the resulting embryo(s) are transferred to the uterine cavity where implantation and pregnancy may occur. Zygote Intrafallopian Transfer (ZIFT): An infertility treatment that involves obtaining mature eggs (oocytes) by surgical or nonsurgical procedures and combining the eggs and sperm in a laboratory setting. The fertilized oocytes, or zygotes, are transferred to the fallopian tube before cell division occurs. The intent of this procedure is to have the zygote travel to the uterus via the fallopian tube as it would in a fertile woman.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

FAMILY PLANNING

TITLE:

Birth Control

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 7/12/01, 6/18/03, 7/21/05, 5/4/06, 8/28/07, 5/22/08, 4/15/09, 6/23/09, 4/21/10, 04/26/12, 09/27/12, 04/25/13

Policy Number: F-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

For Bolded Items in Cover and Not Covered Sections -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services A. FEDERAL/STATE MANDATED REGULATIONS 1.

Oklahoma Title 365:40-5-20 (10)(C) Basic health care services: Basic health care services shall include: (10) Preventive health services, which shall be made available to enrollees and shall include at least the following: (C) Periodic health evaluations for adults to include voluntary family planning services.

B. STATE MARKET PLAN ENHANCEMENTS -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services. 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: See Section B for coverage of birth control device. For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services. For Bolded Items in Cover and Not Covered Sections -For information related to those items

covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services 1. 2.

3. 4. 5. 6.

Office visits for general education, counseling, and instruction on birth control methods Sterilization a. Vasectomy b. Tubal ligation (Note: This includes the tubal occlusive procedure, i.e., Essure. Follow-up examinations will be covered in accordance with the FDA guidelines. FDA information available at http://www.fda.gov/cdrh/pdf2/p020014.html.) (See Note Above) Depo-Provera injections (See Note Above) Removal of Norplant (See Note Above) Professional services related to insertion and removal of Intrauterine device (IUD) (See Note Above) Pregnancy testing (See Note Above)

D. NOT COVERED For Bolded Items in Cover and Not Covered Sections -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services 1. 2.

3. 4. 5. 6. 7.

Over-the-counter supplies and devices Implantable birth control devices/rods (e.g., IUD, IMPLANON™) when member has specific exclusion for IUD or implantable birth control as stated in the member’s Schedule of Benefits. Refer to the member’s Schedule of Benefits to determine coverage eligibility. Also see Section A and/or B. (See Note Above) If the member has the IUD or implantable birth control benefit, the following guidelines apply: a. The device/rod must be FDA approved. b. The applicable copayment/coinsurance will apply. c. Limited to one device/rod and insertion every three years. d. Implant may be removed upon request. Hysterectomy for sterilization purposes Reversal of sterilization Cervical caps unless covered under Section A and/or B. (See Note Above) Diaphragms unless covered under Section A and/or B. (See Note Above) Oral contraceptives unless covered under the supplemental prescription benefit (See Note Above)

E. DEFINITIONS F.

REFERENCES 1.

MCO Combined Evidence EOC & Disclosure Form

SignatureValue™ Benefit Interpretation Policy SUBJECT:

FAMILY PLANNING

TITLE:

Infertility Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 9/1/00, 6/20/02, 6/18/03, 12/5/05, 5/4/06, 5/22/08, 4/21/10, 04/26/12, 04/25/13

Policy Number: F-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

OAC 365:40-5-20. Basic health care services Basic health care services shall include: (1) Physician services including consultant and referral services by a physician, and other health professional services as necessary to provide allopathic, osteopathic, chiropractic, podiatric, optometric, and psychological services. If a service of a physician may also be provided under applicable State law by another type of health professional, an HMO may provide the service through these other health professionals. (2) Outpatient services including diagnostic services, treatment services and x-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at a hospital………………………………………………………………………… (8) Diagnostic laboratory and diagnostic and therapeutic radiological services in support of basic health care services. (9)Home health services provided at an enrollee's home by health care personnel, as prescribed or directed by the responsible physician or their authority designated by the HMO. (10) Preventive health services, which shall be made available to enrollees and shall include at least the following: (A) Services for children from birth to age 21 as determined by the American Academy of Pediatrics in "Guidelines for Health Supervision"; (B) Immunizations for adults and children as recommended by the Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention, except those required for foreign travel and employment; (C) Periodic health evaluations for adults to include voluntary family planning services; and (D) Preventive services identified through the HMO quality assurance program designed to contribute to achieving the U.S. Department of Health and Human Services "Healthy People 2010" objectives…………………………………………………………………….

STATE MARKET PLAN ENHANCEMENTS

1.

Members may have coverage for infertility services depending on the member’s employer group plan. Refer to the member’s EOC/SOB or contact the Customer Service Department to determine coverage eligibility. If member has the benefit coverage, refer to the Basic Infertility Services policy for specific coverage information.

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless member has the infertility benefit as stated in Section A and/or B.

D.

NOT COVERED

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

FOOT CARE AND PODIATRY SERVICES

TITLE:

Foot Care and Podiatry Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 3/1/01, 9/17/03, 10/20/05, 8/28/07, 7/16/08, 4/15/09, 4/21/10, 04/26/12, 04/25/13

Policy Number: F-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1. Oklahoma Senate Bill No. 3021 2.1: Podiatric appliances for prevention of complications

associated with diabetes. 2. Oklahoma Senate Bill No. 3021 3.a: Podiatric health care provider services as are deemed medically necessary to prevent complications from diabetes. B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Medically necessary foot care when criteria are met. Routine Foot Care Foot care services that are considered routine are RECOMMENDED for the following (CMS, 2003): a. Services are performed as a necessary and integral part of otherwise covered services such as diagnosis and treatment of ulcers, wounds, infections, and fractures. b. The presence of a systemic condition such as metabolic, neurologic or vascular conditions that may require scrupulous foot care by a professional. Procedures, that are otherwise considered routine, may be covered when systemic condition(s) demonstrated through physical and/or clinical findings result in severe circulatory embarrassment or areas of diminished sensation in the legs or feet when such services may pose a hazard if performed by a nonprofessional.

c.

Patients with systemic conditions such as diabetes mellitus, chronic thrombophlebitis, and peripheral neuropathies involving the feet must be under the active care (SEE DEFINITION) of a doctor of medicine or doctor of osteopathy who documents the condition in the patient’s medical record. Treatment of warts, including plantar warts, may be covered. Coverage is limited to those services provided for treatment of warts located elsewhere on the body. 1) For ambulatory members, the physician must document that both of the following criteria are met: a. There is clinical evidence of mycosis of the toenail b. The member has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate 2) For non-ambulatory members, the physician must document that both of the following criteria are met: a. There is clinical evidence of mycosis of the toenail b. The member has pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate

Foot Examination Please refer to Clinical Practice Guideline: Diabetes Management Guidelines Also see Shoes and Foot Orthotics policy D.

NOT COVERED 1. 2. 3. 4. 5. 6. 7.

E.

DEFINITIONS 1.

2.

F.

Routine foot care, except as defined in Section C or included as a supplemental benefit Services or devices directed toward the care or correction of flat foot conditions Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot Cosmetic surgery for abnormalities of the feet Vitamin B-12 injections to strengthen tendons, ligaments, etc. of the foot Oral prescription drugs solely for cosmetic purposes Over-the-counter appliances, medications and topical agents for the treatment of foot disorders

Podiatry Services: Treatment of disorders/ailments of the foot, heel, ankle and leg by medical, orthopedic, and surgical means by a Medical Doctor (MD), Orthopedic Doctor (OD), or Doctor of Podiatric Medicine (DPM). Active Care: Treatment and/or evaluation of the complicating disease process during the sixmonth period prior to rendition of the routine care or care provided shortly after the services were furnished, usually as a result of a referral.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

GENETIC TESTING

TITLE:

Genetic Testing

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 9/1/00

Effective Date: 1/16/01

Review Date: 6/18/03, 3/17/04, 2/16/06, 2/14/08, 2/18/09, 2/17/10, 2/16/11, 7/15/11, 02/23/12, 02/28/13, 07/25/13

Policy Number: G-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Genetic testing and counseling when criteria are met. See Medical Management Guidelines: Genetic Testing for Hereditary Breast And/Or Ovarian Cancer Syndrome (HBOC); and Preventive Care Services (Internal, Internal, Provider Portal or Member).

D.

NOT COVERED 1. 2. 3. 4. 5.

Genetic testing that does not meet criteria Genetic testing for the sole purpose of determining the sex of a fetus Genetic testing when member has no medical indication, i.e., high risk status or strong family history of a genetic abnormality Genetic testing for non- UnitedHealthcare members Genetic testing of a child to determine the child’s future reproductive status

6.

7.

E.

DEFINITIONS 1.

2.

F.

Genetic testing and counseling to screen newborns, children or adolescents to determine carrier status for inheritable disorders when there would be no immediate medical benefit (e.g., application of measures that can prevent the disease, delay its onset, limit its severity or prevent secondary disabilities) or when the test results would not be used to initiate medical interventions during childhood. Genetic testing and counseling for non-medical reasons (e.g., court ordered tests, work related tests, paternity tests)

Genetic Testing: The analysis of an individual's genetic material. Among the purposes of genetic testing are gathering information on an individual's genetic predisposition to particular health conditions and confirming a diagnosis of genetic disease. Genetic Counseling: Process in which a genetic counselor educates individuals or families about a particular genetic disease or the risk of a predisposition for genetic disease in order to assist patients to make informed reproductive or medical decisions.

REFERENCES

WWW SignatureValue™ Benefit Interpretation Policy SUBJECT:

HEARING

TITLE:

Hearing Screening, Hearing Examinations and Hearing Aids

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/2000

Review Date: 9/12/02, 6/18/03, 8/31/04, 8/17/06, 7/16/08, 8/05/08, 9/1/09, 10/21/09, 11/23/09, 2/17/10, 9/2/10, 02/02/11, 2/16/11, 6/21/11, 8/16/11, 02/23/12, 08/23/12, 08/22/13

Policy Number: H-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

Oklahoma Statutes §36-6060.7. Audiological services and hearing aids for children. A. 1. Any group health insurance or health benefit plan agreement, contract or policy, including the State and Education Employees Group Insurance Board and any indemnity plan, not-forprofit hospital or medical service or indemnity contract, prepaid or managed care plan or provider agreement, and Multiple Employer Welfare Arrangement (MEWA) or employer selfinsured plan, except as exempt under federal ERISA provisions, that is offered, issued, or renewed on or after the effective date of this act shall provide coverage for audiological services and hearing aids for children up to eighteen (18) years of age. 2. Such coverage: a. shall only apply to hearing aids that are prescribed, filled and dispensed by a licensed audiologist, and b. may limit the hearing aid benefit payable for each hearing-impaired ear to every forty-eight (48) months; provided, however, such coverage may provide for up to four additional ear molds per year for children up to two (2) years of age. B. Nothing in this section shall be construed to extend the practice or privileges of any health care provider beyond that provided in the laws governing the provider’s practice and privileges. C. This requirement shall not apply to agreements, contracts or policies that provide coverage for a specified disease or other limited benefit coverage, or groups with fifty or fewer employees.

STATE MARKET PLAN ENHANCEMENTS 1.

Members may have additional hearing aid benefit. Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact Member Services Department to determine eligibility.

2.

Hearing aids for children up to eighteen (18) years of age: a. Standard hearing aid, per ear, every forty-eight (48) months (standard hearing aid is defined as an "In-the-ear" or "All-in-ear" device)

b. Up to four (4) additional ear molds per year for children up to two (2) years of age. c. Replacement parts and repair of hearing aid(s) C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

3.

4.

5.

6.

Hearing screening services when performed in the Primary Care Physician's office (Note: These may include use of an office screening audiometer, tuning fork, or whispered number recognition.) Hearing examinations to evaluate hearing loss a. Examples include, but are not limited to: 1) Testing for hearing loss secondary to acute illness or injury 2) Testing for hearing loss secondary to drug therapy Further diagnostic testing by a Participating Audiologist, including hearing and balance assessment services, is covered when the member's PCP orders the testing as part of the diagnostic evaluation, or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. (Note: These services are not covered when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for or the appropriate type of a hearing aid, unless member has a supplemental hearing aid benefit.) Cochlear implant when criteria are met. The initial placements of the cochlear implant external components that are done during the surgery are covered under the surgical benefit. However, if replacement external components of the cochlear implant system are needed at any point after that, then the benefit for those replacement items is under Prosthetics and subject to Prosthetic benefits. Note: Cochlear implant is covered under the medical benefit. See Medical Management Guideline: Cochlear Implant (click Internal, Provider Portal or Member). Hearing aids (wearable hearing aids) required for the correction of a hearing impairment are covered when ordered by a physician. Coverage includes the hearing aid, fitting, assessment, and evaluation of the hearing aid. Effective January 1, 2012 “Limited to one hearing aid (including repair and replacement) per hearing impaired ear every three years.” Please refer to your Schedule of Benefits for any applicable Copayments, deductible amounts, and annual dollar limit benefit maximum. Bone-anchored hearing aids (BAHA) are covered only when the member has either of the following: “This policy becomes effective for group contracts issued, amended or renewed on or after January 1, 2010. Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) to determine the member’s policy renewal date” a. Craniofacial anomalies in which abnormal or absent ear canals preclude the use of a wearable hearing aid, or

b.

Hearing loss of sufficient severity that it cannot be adequately remedied by a wearable hearing aid. Benefits limited to one bone anchored hearing aid per member who meets the above coverage criteria during the entire period of time the member is enrolled in the health plan. Replacement external components are covered under DME and are subject to DME benefit limitations. See D.1. Note: Coverage for bone-anchored hearing aids (BAHA) which use a headband, rather than osseointegration, are covered as “wearable hearing aids”, rather than as semi-implantable hearing aids. Therefore, the benefit limitation of one single bone anchored hearing aid per member’s enrollment does not apply. See Medical Management Guideline: Implantable Hearing Devices and Bone Anchored Hearing Aids (click Internal, Provider Portal or Member). D.

NOT COVERED 1. 2.

Repairs and/or replacement for a bone anchored hearing aid are not covered, other than for malfunctions. Deluxe models and upgrades that are not medically necessary are not covered Hearing aid dispensing fees, batteries, accessories, cords, assistive listening devices, and communications devices unless required by state mandate.

E.

DEFINITIONS 1. Bone-Anchored Hearing Aids (BAHA): An osseointegrated semi-implantable electromagnetic hearing aid used in the treatment of sensorineural hearing loss in patients who are not candidates for an air-conduction hearing aid.

F.

REFERENCES 1.

American Disabilities Act http://www.ada.gov/pubs/ada.htm

SignatureValue™ Benefit Interpretation Policy SUBJECT:

HOME HEALTH

TITLE:

Home Health Care Visits

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 5/3/01, 12/5/02, 6/18/03, 12/18/03, 3/17/04, 12/15/04, 5/4/06, 5/22/08, 9/25/08, 9/1/09, 9/2/10, 8/16/11, 8/23/12, 08/22/13

Policy Number: H-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1. None

B.

STATE MARKET PLAN ENHANCEMENTS 1.

For Federal employees, refer to the Federal Employees Health Benefits (FEHB) Program brochure for specific benefit description.

Note: Home health visits solely for the purpose of diabetes self-management training (including training related to medical nutritional therapy) do not count towards the home health benefit limit. C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Home health care visits under the direct care or supervision of a registered nurse or licensed vocational nurse, subject to the following criteria: a. The member must be homebound or confined to an institution that is not a hospital or is not primarily engaged in providing skilled nursing or rehabilitation services. b. The member needs medically necessary skilled nursing visits or needs physical, speech, or occupational therapy; and c. The home health care visits must be furnished under a plan of treatment that is established, periodically reviewed (at least every 30 days), and ordered and authorized by a UnitedHealthcare Participating/Contracting physician.

2.

D.

NOT COVERED 1. 2. 3. 4.

5. 6. E.

IMPORTANT NOTE: The home health care services must be furnished on a per visit basis in the member’s place of residence. For Custom Plan, refer to the EOC/SOB for home health benefit limitations. Examples of covered benefits include, but are not limited to: a. Infusion therapy medications and supplies and laboratory services as prescribed by a Participating/Contracting Physician to the extent such services would be covered by UnitedHealthcare had the member remained in the hospital, rehabilitation or Skilled Nursing Facility. b. Intramuscular injections (e.g., antibiotics) c. Subcutaneous injections other than self-administered medications (e.g., insulin, Imitrex) d. Insertion of catheters or extensive decubiti care (Stage III or Stage IV) aseptic or sterile dressing changes to open wound e. Home health aides who provide supportive care in the home such as bathing are only available when medically necessary and ordered in conjunction with skilled nursing or skilled therapy services such as PT, OT or ST (Note: Wherever possible, the home health aides should be provided by the same agency providing the skilled nurse or skilled therapist.) f. Pre-assessment visit in anticipation of home health care visits g. Phototherapy for neonatal hyperbilirubinemia h. Physical, occupational, or speech therapy that is provided on a per visit basis i. Medical supplies, durable medical equipment when authorized in conjunction with the home health care visits Note: Some members may have access to A Solution for Caregivers program. Contact the Customer Service Department to determine eligibility.

Routine/custodial/convalescent care, long term physical therapy and/or rehabilitation Private duty nursing care (Note: For Federal employees, refer to the Federal Employees Health Benefits (FEHB) Program brochure for specific benefit description.) Homemaker services unrelated to member care or home meal delivery services (e.g., Meals on Wheels) or transportation services (e.g., Dial-a-Ride) Oral prescription drugs provided by a home health provider, unless the member has a supplemental pharmacy benefit and the oral medications are obtained through a contracted UnitedHealthcare pharmacy provider Home health care visit for a blood draw, unless the member has a need for another qualified skilled service and meets all home health eligibility criteria Services in the home provided by relatives or other household members

DEFINITIONS 1.

2.

Custodial Care: Non-medically necessary personal health care for the purpose of assisting a member in meeting the requirements of daily living. It does not require the continuing attention of trained medical or paramedical personnel. Home Health Aides: Trained individuals who provide, when medically necessary, personal care such as bathing, exercise assistance and light meal preparation. This service is only available when ordered along with skilled nursing and/or therapy services.

3.

4.

5.

6.

7.

8.

9.

F.

Home Health Care Visit: Defined as up to two (2) hours of skilled services by a registered nurse or licensed vocational nurse or licensed therapist or up to four (4) hours of home health aide services. Homebound: A person does not need to be bedridden to be confined to the home. However, the physical condition must be such that there exists a normal inability to leave home, leaving requires a considerable and taxing effort, and absences from the home are infrequent, of relatively short duration, and are attributable to the need to receive medical treatment. Place of Residence: Wherever the member makes their home. This may be their own dwelling, an apartment, a relative’s home, home for the aged, a custodial care facility, or some other type of institution. Private Duty Nursing Services: Private duty nursing services encompass nursing services for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility Self-injectable (self-administered) Medications: Drugs which are either generally selfadministered by intramuscular injection at a frequency of one or more times per week, or which are generally self-administered by the subcutaneous route. Skilled Services: Services that must be provided by a licensed nurse (either RN or a LVN) under the supervision of a registered nurse and/or the provision of a physical, occupational, and/or speech therapist for those members in need. Social Services: Physician prescribed services provided by a medical social worker that assist the member and family to better cope with the stresses of illness and/or disability and provide information, assistance, and support in accessing and obtaining other community services.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

HOSPICE CARE AND SERVICES

TITLE:

Hospice Care and Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/5/99

Effective Date: 1/1/00

Review Date: 2/5/02, 1/14/04, 3/24/05, 2/6/07, 2/18/09, 2/17/10, 2/16/11, 02/23/12, 02/28/13

Policy Number: H-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Department of Insurance Title 74, Chapter 37, Section 1303: 14."Comprehensive benefits" means benefits which reimburse the expense of hospital room and board, other hospital services, certain outpatient expenses, maternity benefits, surgical expense, including obstetrical care, in-hospital medical care expense, diagnostic radiological and laboratory benefits, physicians' services provided by house and office calls, treatments administered in physicians' office, prescription drugs, psychiatric services, Christian Science practitioners' services, Christian Science nurses' services, optometric medical services for injury or illness of the eye, home health care, home nursing service, hospice care, and such other benefits as may be determined by the Board. Such benefits shall be provided on a copayment or coinsurance basis, the insured to pay a proportion of the cost of such benefits, and may be subject to a deductible that applies to all or part of the benefits as determined by the Board.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Hospice care is covered only: a. For those members who have been certified by their attending physician as terminally ill (life

expectancy of 6 months or less)

2. 3.

4. 5.

6.

Note: Should the member continue to live beyond the original hospice qualifying life expectancy, the member’s attending physician needs to re-evaluate the member’s condition and determine the appropriateness of continuing hospice. b. When provided by a certified hospice directly or indirectly when arrangements are made by the selected hospice c. If a written plan of care is established by the member’s physician, attending physician, medical director or designee of the hospice, and an interdisciplinary group (this group must have at least one physician, one registered nurse, one social worker, and one pastoral care or other counselor) There are no day limits; however, the member may be under case management or designee Respite care for short term inpatient care is provided for the member only when necessary to provide relief to the family members or caregiver, only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time. The hospice is responsible for providing any and all services indicated as necessary for the palliation and management of the terminal illness and related conditions in the plan of care. Skilled nursing facility (SNF) if: a. Residential care is paid for by the member b. The member is eligible for Medicaid and the facility is being reimbursed for the member’s care by Medicaid c. The hospice and facility have a written agreement under which the hospice takes full responsibility for the overall management of the member’s hospice care and the facility agrees to provide room and board for the member Examples of covered benefits include, but are not limited to: a. Nursing care provided by or under the direct supervision of a licensed nurse b. Medical social services provided by a licensed social worker and under the direction of a physician c. Physician services performed by a Physician except that the services of the hospice medical director or the Physician member of the interdisciplinary group (the hospice team) must be performed by a medical doctor (M.D.) or doctor of osteopathy (D.O.) d. Short term inpatient care provided in a participating hospice inpatient unit or in a SNF or Intermediate Care Facility (ICF) for procedures necessary for pain control, or acute or chronic symptom management or respite for the member’s family or other persons caring for the member at home e. Medical equipment, supplies, and drugs that are used primarily for the relief of pain related to the terminal illness. Equipment includes durable medical equipment and other items related to the management of the terminal illness. Equipment for use in the member’s home is provided by hospice. f. Home health aide and homemaker services that must be provided under the general supervision of a licensed nurse g. Continuous home care only as necessary to maintain the terminally ill member at home h. Physical, occupational, and/or speech therapy if provided for the purposes of symptom control or to enable the member to maintain activities of daily living and basic functional skills

i.

General inpatient hospital care for procedures such as medication adjustment, observation or other stabilizing treatment such as psychosocial monitoring for a member whose family is unwilling to permit needed care to be provided in the residence Note: The care and services described in “a” and “h” above may be provided on a 24-hour, continuous basis only during periods of crisis and only as necessary to maintain the terminally ill member at home. D.

NOT COVERED 1. 2.

E.

DEFINITIONS 1. 2.

3.

4.

5. 6. 7.

8. 9.

F.

Members who do not meet the definition of terminally ill Hospice services that are not reasonable and necessary for the management of a terminal illness (e.g., care provided in non-certified hospice programs)

Acute Inpatient Hospital Care: May be required for procedures necessary for the member’s pain control or symptom management. Attending Physician: May be either a M.D. or D.O. who may or may not be an employee of the hospice and who is identified by the member, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. The medical director or a staff physician of the hospice may perform attending physician functions. Continuous Home Care: Care provided during a period of crisis that occurs when a member requires continuous care (primarily nursing care) to achieve palliation or management of acute medical symptoms to maintain the terminally ill member at home. Continuous home care provides a minimum of 8 hours of care during a 24-hour day that begins and ends at midnight. The 8 hours may be split. When fewer than 8 hours of nursing care are required, the services are covered as routine home care rather than continuous home care. At least half of the time a RN or a LVN/LPN must provide the care. A homemaker or home health aide may supplement the nursing care. Home Health Aide and Homemaker Services: Programs/staff that provide personal care and household services to maintain a safe and sanitary environment for the terminally ill member. These services must be provided under the general supervision of a RN. Hospice Care: A method for caring for terminally ill members. Hospice care emphasizes supportive services, such as home care and pain control, rather than cure-oriented services. Palliation: Reduction of the member’s pain and suffering without curing. Period of Crisis: A period in which a member requires continuous care that is primarily nursing care for palliation or medical management of acute symptoms. If the caregiver has been a family or friend who is unable or unwilling to provide care for the member, this may be considered a period of crisis. When less than 8 hours of care are required, the services are covered as routine care instead of continuous care. Respite Care: Short-term inpatient care provided to the member only when necessary to provide relief to the family members or caregiver. Terminally Ill: Describes members with a life expectancy of 6 months or less, if the illness runs its normal course.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

HOSPITAL OBSERVATION

TITLE:

Observation Care (Outpatient Hospital)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7-16-08

Effective Date: 02/01/13

Review Date: 11/15/10, 6/21/11, 12/20/11, 12/27/12

Policy Number: H-006

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A. FEDERAL/STATE MANDATED REGULATIONS 1.

None

B. STATE MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Outpatient hospital observation services are covered when coverage criteria are met. Outpatient observation services are covered for up to 48 hours and may include: a. Use of a bed within a hospital for the purpose of observing the member’s/enrollee’s condition b. Periodic monitoring by the hospital’s staff to evaluate an outpatient’s condition and/or determine the need for a possible admission to the hospital as an inpatient (this includes medically necessary laboratory tests and radiology/diagnostic exams/Medical Imaging. Factors to be considered when making the decision to admit include such things as: • The severity of the signs and symptoms exhibited by the patient; • The medical predictability of something adverse happening to the patient; • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 ours or more) to assist in assessing whether the patient should be admitted; and • The availability of diagnostic procedures at the time when and at the location where the patient presents.

Notes:

•

•

• • •

•

In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. See bullet 6 below for when inpatient can be changed to outpatient Hospitals may bill for patients who are “direct admissions” to observation. A “direct admission” occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department (ED) Copayment or Co-insurance may apply as either Emergency Room Services or Observation, check member’s/enrollee’s Schedule of Benefit document A patient admitted to observation and then admitted to inpatient status on the same day is billed using inpatient admit inpatient admission codes only A patient admitted to observation and then admitted to inpatient status on a different day may be billed with both the initial observation codes and also hospital admission codes on the subsequent day. When the hospital utilization review determines* that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient provided all of the following conditions are met: 1. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital; 2.

The hospital has not billed for the inpatient admission;

3. The physician’s concurrence with the utilization review decision is documented in the patient’s medical record. * Hospital determinations are made by the party who is contractually responsible for hospital utilization

D.

NOT COVERED 1. 2.

3. 4.

E.

Services that are not reasonable and necessary for the diagnosis or treatment of the member/enrollee Outpatient observation services that are provided only for the convenience of the member/enrollee or his/her family or physician. (e.g., following an uncomplicated treatment or a procedure, physician busy when patient is physically ready for discharge, patient awaiting placement in a long term care facility) Any substitution of an outpatient observation service for a medically appropriate inpatient admission Standing orders for observation following outpatient surgery

DEFINITIONS 1.

Observation Care: Well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who

present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge. F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

HOSPITAL SERVICES

TITLE:

Inpatient Hospital Admissions and Care

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 12/5/02, 6/18/03, 5/19/05, 5/10/07, 12/16/08, 8/13/09, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: H-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1. 2.

C.

None

For Federal employees, refer to the Federal Employees Health Benefits (FEHB) Program brochure for specific benefit description. Private duty nursing care is covered when medically necessary.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Acute inpatient hospital services must be medically necessary and provided through the UnitedHealthcare network, unless it is an emergency situation or an urgently needed service while temporarily outside of the area (see Medical Necessity and Emergency and Urgent Services policies). Examples include, but are not limited to: a. Services provided by a licensed physician, including: 1) Services of a consultant 2) Referral services b. Room and board c. General nursing care

d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t.

Meals and special diets when medically necessary Use of the operating room (OR) and related facilities (e.g., Recovery Room) Use of medically necessary inpatient units required to provide care, treatment and services as required (e.g., ICU, CCU, Telemetry Unit) Miscellaneous hospital charges for all medically necessary care, treatment and services as required Coordinated hospital discharge planning services Diagnostic laboratory and therapeutic radiological services (see Laboratory: Routine Diagnostic Testing and Services and Radiology: Diagnostic and Therapeutic policies) Drugs, medications and biologicals while member is an inpatient Anesthesia and oxygen services Chemotherapy (see Chemotherapy policy) Radiation therapy Physical, occupational and speech therapies (see Rehabilitation: Medical - Physical, Occupational and Speech Therapy policy) Respiratory therapy Administration of whole blood and blood plasma (see Blood and Blood Products policy) Maternity care and services (see Maternity Care/Newborn Care policy) Transplantation services (see Organ and Tissue Transplants policy) Detoxification for inpatient chemical dependency/substance abuse (see Detoxification: Chemical Dependency/Substance Abuse policy) Anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center, when the clinical status or underlying medical condition of the patient requires dental procedures that ordinarily would not require general anesthesia to be rendered in a contracted hospital or contracted surgery center setting. (See Dental Care and Oral Surgery policy)

Note: Bloodless medicine and/or surgery for members who choose not to receive blood or selected blood products, only when available through the contracting provider. All bloodless medicine or surgery must be authorized by the Member’s Participating Medical Group/IPA or the member may be financially responsible. Authorization requests for bloodless medicine cannot be guaranteed because the capabilities and resources vary depending on the member’s chosen Participating Medical Group/IPA. Members requesting information on bloodless programs can access the following website: www.noblood.org Members should be aware that UnitedHealthcare has no affiliation with the organization and coverage is not guaranteed. D.

NOT COVERED 1.

Services and items not considered reasonable and medically necessary for the diagnosis, care and treatment of an illness or injury suffered by the hospitalized member Examples include, but are not limited to: a. Private rooms, unless medically necessary b. Personal or comfort items c. Private duty nursing care (See Section B for specific FEHB benefit) d. Early admission to perform pre-operative testing unless prior approved e. Early admission for the member, member’s family or member’s physician’s convenience

f. g. h. i. E.

DEFINITIONS 1.

F.

Continued stay in the hospital for services that could have been appropriately and safely performed as an outpatient or the member could have been discharged Take home medications and/or supplies unless member has a supplemental pharmacy benefit Elective non-medically necessary surgery and procedures (see Surgery: Cosmetic, Reconstructive or Plastic policy) Experimental procedures and items

Private Duty Nursing Services: Private duty nursing services encompass nursing services for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

HOSPITAL SERVICES

TITLE:

Outpatient Hospital Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 6/18/03, 5/19/05, 5/10/07, 12/16/08, 8/13/09, 10/21/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: H-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2. 3.

Outpatient services in a non-hospital based health care facility or in a hospital a. Examples include, but are not limited to: 1) Diagnostic testing, including laboratory and radiological services (see Laboratory: Routine Diagnostic Testing and Services and Radiology: Diagnostic and Therapeutic policies) 2) Therapeutic radiological services (X-rays) (see Radiology: Diagnostic and Therapeutic policy) 3) Treatment services for the provision of basic health services 4) Prior authorized outpatient surgery Mental health outpatient services (see Mental Health: Outpatient policy) Detoxification and chemical dependency outpatient services (see Detoxification: Chemical Dependency/Substance Abuse policy)

4. 5.

Outpatient rehabilitative services, including physical, speech and occupational therapies (see Rehabilitation: Medical - Physical, Occupational and Speech Therapy policy) Anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center, when the clinical status or underlying medical condition of the patient requires dental procedures that ordinarily would not require general anesthesia to be rendered in a contracted hospital or surgery center setting. (see Dental Care and Oral Surgery policy)

Note: Bloodless medicine and/or surgery for members who choose not to receive blood or selected blood products, only when available through the contracting provider. All bloodless medicine or surgery must be authorized by the Member’s Participating Medical Group/IPA or the member may be financially responsible. Authorization requests for bloodless medicine cannot be guaranteed because the capabilities and resources vary depending on the member’s chosen Participating Medical Group/IPA. Members requesting information on bloodless programs, access the following website: www.noblood.org Members should be aware that UnitedHealthcare has no affiliation with the organization and coverage is not guaranteed. D.

NOT COVERED 1.

Examples of non-covered outpatient services include, but are not limited to: a. Cosmetic surgery only for the purpose of improving the member’s appearances rather than improving a physiological function (see Surgery: Cosmetic, Reconstructive or Plastic policy) b. Non-medically necessary and/or non-authorized outpatient surgeries and/or procedures c. Experimental/investigational treatment on an outpatient basis d. Physical rehabilitation day treatment programs

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

IMMUNIZATIONS/VACCINATIONS

TITLE:

Immunizations/Vaccinations

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 8/1/00

Review Date: 5/12/00, 11/3/00, 5/3/01, 12/5/02, 6/18/03, 5/19/05, 11/1/06, 2/6/07, 11/6/07, 12/16/08, 12/16/09, 11/15/10, 12/20/11, 10/25/12

Policy Number: I-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Bill No. 277: Hepatitis A and Hepatitis B immunizations are covered for children from birth to age eighteen.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Unless otherwise mandated, immunizations and vaccinations are covered in accordance with UnitedHealthcare’s current Preventive Health Services. 1.

2.

Vaccinations or immunizations that are directly related to the treatment of an injury, a condition, or direct exposure to a disease, or are otherwise determined to be medically necessary Examples include, but are not limited to: 1) Anti-rabies vaccine 2) Tetanus antitoxin 3) Booster vaccines 4) Botulin antitoxin 5) Anti-venom vaccine 6) Immunoglobulin Meningococcal vaccine in accordance with UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member).

3. 4. 5. 6.

7.

8.

D.

NOT COVERED 1.

2.

3. E.

Vaccines and immunizations for the purpose of international travel unless the immunizations are also recommended in UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). Refer to Section B for state-specific Market Plan Enhancements. Vaccines required for employment due to exposure risk of employment or for educational purposes unless vaccines are also recommended in UnitedHealthcare’s current Preventive Health Services, or covered under Section B Vaccinations not meeting the criteria listed above

DEFINITIONS 1. 2.

3.

F.

Pneumococcal 7-valent conjugate vaccine (PrevnarTM) in accordance with UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). Human Papillomavirus (HPV) vaccine in accordance with the UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). Immunizations that are age appropriate and in accordance with UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). Hepatitis B vaccination for all unvaccinated adults at risk for hepatitis B virus (HBV) infection and for all adults seeking protection from HBV infection. Acknowledgement of a specific risk factor is not a requirement for vaccination, per UnitedHealthcare’s Preventive Health Services, which are in accordance with ACIP recommendations. Influenza vaccine immunization against “Seasonal Influenza” for children age 6 months through 18 years, for adults age 19 through 49 years who are at increased risk for complications or transmission to high risk persons, and for all adults age 50 years and older, in accordance with UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). H1N1 vaccine administration is covered for all members, with no copays, deductibles or coinsurance fees. Members may obtain immunization from any available source, which may include local public health clinics, physicians who are participating in the H1N1 vaccine administration program, retail pharmacies, or other mass immunization sources. There is no cost for the vaccine itself, which is free from government sources. However, if the member receives immunization from an Out-of-Network provider, and is required to pay an up-front charge for administration of the H1N1 vaccine, members may submit a claim for reimbursement. UnitedHealthcare will reimburse the member up to the local Medicare rate or billed charges, whichever is less. To request reimbursement, the member should submit a copy of receipt, full name, member ID number, date of service, and type of service (H1N1 flu vaccine administration) to the address listed on the back of the member ID card.

Immunization: The production of immunity by artificial means. Preventive Health Services: UnitedHealthcare’s services for preventative health services which are developed based on scientific evidence. UnitedHealthcare’s current Preventive Health Services (click Internal, Provider Portal or Member). Vaccination: A means of producing immunity to a disease by using a vaccine, or a special preparation of antigenic material, to stimulate the formation of appropriate antibodies.

REFERENCES

1. 2.

3.

UnitedHealthcare Preventive Health Services American Academy of Pediatrics, Policy Statement: Services for the Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate Vaccine (Prevnar), Pneumococcal Polysaccharide Vaccine, and Antibiotic Prophylaxis (RE9960) Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians

SignatureValue™ Benefit Interpretation Policy SUBJECT:

INCONTINENCE

TITLE:

Incontinence Control (Adult)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 7/12/01, 12/5/02, 9/17/03, 2/16/06, 2/14/08, 4/15/09, 4/21/10, 04/26/12, 04/25/13

Policy Number: I-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

3. 4.

Conservative treatments a. Examples include, but are not limited to: 1) Habit training 2) Prompted voiding 3) Routine/scheduled toileting 4) Kegel exercises Mechanical or hydraulic incontinence control devices for the management of urinary incontinence in members with permanent anatomic and neurologic dysfunctions of the bladder (e.g., artificial sphincter) Collagen implants. See the Medical Management Guideline: Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence for coverage criteria (click Internal, Provider Portal or Member). Biofeedback for the treatment of stress and/or urge urinary incontinence. See the Medical Management Guideline: Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence for coverage criteria (click Internal, Provider Portal or Member).

5. 6.

D.

NOT COVERED 1.

E.

Electrical stimulators, other than sacral nerve stimulators as described in the Medical Management Guideline: Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence for coverage criteria (click Internal, Provider Portal or Member).

DEFINITIONS 1.

F.

Prescription drugs used to treat urinary incontinence if the member has a prescription benefit (e.g., anticholinergic drugs) Sacral nerve stimulator for urinary urge incontinence. See the Medical Management Guideline: Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence for coverage criteria (click Internal, Provider Portal or Member).

Mechanical or Hydraulic Incontinence Control Devices: Incontinence control devices that achieve control of urination by compressing the urethra.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

LABORATORY SERVICES

TITLE:

Routine Laboratory Diagnostic Testing and Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 12/5/02, 3/20/03, 3/24/05, 5/4/06, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: L-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2. 3.

Routine diagnostic laboratory services in support of basic health care services to be used in the screening or detection of disease and determined to be medically necessary Laboratory services provided as either an inpatient or outpatient service Examples include, but are not limited to: a. Blood testing b. Urinalysis c. HIV testing 1) For member determined by the Primary Care Physician to be at primary or secondary risk for HIV infection. HIV testing would be limited to a frequency not to exceed more than once every six months. 2) In combination or if present for an extended period of time (two or more months), HIV testing is covered as diagnostic testing for symptomatic conditions. 3) Routine testing at the discretion of the PMG/IPA or UnitedHealthcare Medical Director prior to major medical procedures, e.g., major organ transplants.

d. Pre and/or post surgical diagnostic testing e. Culture and Sensitivity f. Biopsy readings g. Routine lab services Also see the Medical Management Guideline: Preventive Care Services (click Internal, Provider Portal or Member) D.

NOT COVERED 1. 2.

Non-medically indicated or unnecessary routine diagnostic laboratory services Examples include, but are not limited to: a. Paternity testing services b. Pre-marital blood testing c. Laboratory services for drug screens or to determine blood alcohol, as required by law d. Employer requested drug testing e. Experimental or unproven laboratory tests not medically indicated f. School admissions and athletic requirements g. Autopsy h. Laboratory tests or procedures in preparation for or during a non-covered service i. Routine or maintenance laboratory tests when the member is outside of the service area (these are not unforeseen, urgent or emergency services)

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

MATERNITY and NEWBORN CARE

TITLE:

Maternity and Newborn Care

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 9/1/00, 1/5/01, 6/18/03, 12/15/04, 7/25/06, 8/17/06 , 2/6/07, 5/10/07, 8/26/08, 12/16/08, 6/19/09, 10/21/09, 11/15/10, 12/20/11, 09/27/12, 10/25/12

Policy Number: M-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

For Bolded Items in Cover and Not Covered Sections -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services A.

FEDERAL/STATE MANDATED REGULATIONS 1.

2.

Newborns’ and Mothers’ Health Protection Act (NMHPA) of 1996, Title VI: Minimum Hospital Stay –UnitedHealthcare and its contracted providers may not restrict the benefits for any hospital length of stay for a mother and her newborn to less than 48 hours following a vaginal delivery and 96 hours following a Cesarean Section (C-Section). Protections for health plans include allowance of discharge before 48–96 hours if the attending physician, in consultation with the mother, makes the decision. Title VII of the Civil Rights Act, as amended by the Pregnancy Discrimination Act: 42 U.S. Code § 2000e (k) The terms “because of sex” or “on the basis of sex” include, but are not limited to, because of or on the basis of pregnancy, childbirth, or related medical conditions; and women affected by pregnancy, childbirth, or related medical conditions shall be treated the same for all employmentrelated purposes, including receipt of benefits under fringe benefit programs, as other persons not so affected but similar in their ability or inability to work, and nothing in section 2000e–2 (h) of this title shall be interpreted to permit otherwise. This subsection shall not require an employer to pay for health insurance benefits for abortion, except where the life of the mother would be endangered if the fetus were carried to term, or except where medical complications have arisen from an abortion: Provided, That nothing herein shall preclude an employer from providing abortion benefits or otherwise affect bargaining agreements in regard to abortion. NOTE: The Pregnancy Discrimination Act (PDA) amended the Title VII of the Civil Rights Act to prohibit employment discrimination based on pregnancy, childbirth, or related medical conditions. In summary, the PDA generally applies to all private and governmental (state and local) employers with 15 or more employees for each working day in at least 20 calendar weeks in the current or preceding calendar year. Any health insurance provided by such employers must cover expenses for pregnancy-related conditions on the same basis as costs for other medical conditions. Health insurance for expenses arising from abortion is not required, except

3.

where the life of the mother is endangered. Pregnancy-related expenses should be reimbursed exactly as those incurred for other medical conditions, whether payment is on a fixed basis or a percentage of reasonable-and-customary-charge basis. The amounts payable by the insurance provider can be limited only to the same extent as amounts payable for other conditions (i.e., no additional, increased, or larger deductible can be imposed). 42 CFR § 1604.10 - Employment Policies Relating to Pregnancy and Childbirth (a) A written or unwritten employment policy or practice which excludes from employment applicants or employees because of pregnancy, childbirth or related medical conditions is in prima facie violation of title VII. (b) Disabilities caused or contributed to by pregnancy, childbirth, or related medical conditions, for all job-related purposes, shall be treated the same as disabilities caused or contributed to by other medical conditions, under any health or disability insurance or sick leave plan available in connection with employment. Written or unwritten employment policies and practices involving matters such as the commencement and duration of leave, the availability of extensions, the accrual of seniority and other benefits and privileges, reinstatement, and payment under any health or disability insurance or sick leave plan, formal or informal, shall be applied to disability due to pregnancy, childbirth or related medical conditions on the same terms and conditions as they are applied to other disabilities. Health insurance benefits for abortion, except where the life of the mother would be endangered if the fetus were carried to term or where medical complications have arisen from an abortion, are not required to be paid by an employer; nothing herein, however, precludes an employer from providing abortion benefits or otherwise affects bargaining agreements in regard to abortion. (c) Where the termination of an employee who is temporarily disabled is caused by an employment policy under which insufficient or no leave is available, such a termination violates the Act if it has a disparate impact on employees of one sex and is not justified by business necessity. (d)(1) Any fringe benefit program, or fund, or insurance program which is in effect on October 31, 1978, which does not treat women affected by pregnancy, childbirth, or related medical conditions the same as other persons not so affected but similar in their ability or inability to work, must be in compliance with the provisions of § 1604.10(b) by April 29, 1979. In order to come into compliance with the provisions of 1604.10(b), there can be no reduction of benefits or compensation which were in effect on October 31, 1978, before October 31, 1979 or the expiration of a collective bargaining agreement in effect on October 31, 1978, whichever is later.

4.

(2) Any fringe benefit program implemented after October 31, 1978, must comply with the provisions of § 1604.10(b) upon implementation. Title 36, OK Statures §6058(C) Amended by Laws 1984, c. 129, § 1, eff. July 1, 1985. §36-6058A. Enrollment of child under parent's health plan - Noncustodial parents. A. Notwithstanding any other provision of law, an insurer shall not deny enrollment of a child under the health plan of the child's parent on the grounds that: 1. The child was born out of wedlock; 2. The child is not claimed as a dependent on the parent's federal income tax return; or 3. The child does not reside with the parent or in the insurer's service area. B. If a child has health coverage through an insurer of a noncustodial parent the insurer shall: 1. Upon request, provide complete information to the custodial person, the designated agency administering the State Medicaid Program, the state agency administering the provisions of 42 U.S.C., Sections 5 through 669, or the Child Support Enforcement Division of the Department of Human Services, regarding any insurance benefits to

5.

which the child is entitled, and any forms, publications, or documents necessary to apply for or to utilize the benefits available through that coverage; 2. Permit the custodial person, the designated agency administering the State Medicaid Program, or the provider with approval, to submit claims for covered services without the approval of the noncustodial parent; and 3. Make payments on claims submitted in accordance with paragraph 2 of this subsection directly to the custodial person, the provider, or the designated agency administering the State Medicaid Program. C. When a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer shall be required: 1. To permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions; 2. To enroll the child under family coverage and deduct the employee’s cost of the coverage from the employee's wages. The enrollment shall be made upon application to the employer by the custodial person, the designated agency administering the State Medicaid Program, or the state agency administering the provisions of 42 U.S.C., Sections 5 to 669, the Child Support Enforcement Division; and 3. Not to disenroll, or eliminate coverage for the child unless the insurer is provided satisfactory written evidence that: a. the court or administrative order is no longer in effect, or b. the child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment; provided, however, the provisions of this subsection shall not apply where the coverage is through a group plan and the group’s coverage through the insurer is discontinued or the noncustodial parent ceases to be eligible for participation in the group plan. ORS 310:550-3-1. Testing of newborns (Effective date 7/15/2008) (a) All newborns in Oklahoma shall be tested by a Certified Newborn Screening Laboratory for phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell diseases, and after June 30, 2004, upon completion of validation studies and establishment of short-term follow-up services, infants shall be screened for cystic fibrosis, congenital adrenal hyperplasia, and medium-chain acyl coenzyme A dehydrogenase deficiency (MCAD) and after October 1, 2007, upon completion of validation studies and establishment of short-term follow-up services, infants shall be screened for biotinidase deficiency, amino acid disorders, fatty acid oxidation disorders, and organic acid disorders detectable via the Department's laboratory technology utilized in newborn screening and approved by the Commissioner of Health; a parent or guardian may refuse screening of their newborn on the grounds that such examination conflicts with their religious tenets and practices. (b) A parent or guardian who refuses the newborn screening blood test of their newborn on the grounds that such examination conflicts with their religious tenets and practices shall also indicate in writing this refusal utilizing the Newborn Screening Program Parent Refusal Form as illustrated in Appendix C of this Chapter. This signed refusal form shall be placed in the newborn's medical record with a copy sent to the Newborn Screening Program Coordinator. ORS 310:550-1-2. Definitions The following words or terms, when used in this Chapter, shall have the following meaning, unless the context clearly indicates otherwise: "Amino Acid Disorders" refers to a group of inherited metabolic conditions in which the body is unable to metabolize or process amino acids properly due to a defective enzyme function. This causes an amino acid or protein build up in the body. If not treated early in life these defects can cause disability, mental retardation or death. Each amino acid disorder is associated with a specific enzyme deficiency. Treatment depends on the specific amino acid disorder. "Biotinidase Deficiency" means an inherited disease caused by the lack of an enzyme that recycles the B vitamin biotin, which if not treated may cause serious complications, including

coma and death. "Certified Laboratory" refers to the Oklahoma State Public Health Laboratory and/or a laboratory approved by the Oklahoma State Department of Health to conduct newborn screening. "CLIA '88" means the Clinical Laboratory Improvement Amendments of 1988, public law 100578. This amendment applies to the Federal Law that governs laboratories who examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment, or the assessment of the health of human beings. "Confirmatory Testing" means definitive laboratory testing needed to confirm a diagnosis. "Congenital Adrenal Hyperplasia" or "CAH" will refer to the most common form of CAH, 21hydroxylase deficiency. This genetic disorder is caused by the lack of an enzyme that the adrenal gland uses to process hormones. Serious loss of body salt and water can result in death. In girls the genitalia may appear as a male's, and can result in incorrect sex assignment. Hormone treatment is required for life. "Congenital Hypothyroidism" means a disease caused by a deficiency of thyroid hormone (thyroxine) production, which if not treated leads to mental and physical retardation. "Cystic Fibrosis" means a multisystem genetic disorder in which defective chloride transport across membranes causes dehydration of secretions. The result is a production of a thick, viscous mucus that clogs the lungs. This leads to chronic lung infections, fatal lung disease, and also interferes with digestion. Early detection and treatment can prevent malnutrition, and enhance surveillance and treatment of lung infections. "Days of Age" means the age of a newborn in 24-hour periods so that a newborn is one day of age 24 hours following the hour of birth. "Department" refers to the Oklahoma State Department of Health. "Discharge" means release of the newborn from care and custody of a perinatal licensed health facility to the parents or into the community. "Disorder" means any condition detectable by newborn screening that allows opportunities, not available without screening, for early treatment and management to prevent mental retardation and/or reduce infant morbidity and mortality. "Fatty Acid Oxidation Disorders" refers to a group of inherited metabolic conditions in which the body is unable to oxidize (breakdown) fatty acids for energy due to a defective enzyme function. If not treated early in life this defect may cause mental retardation or death. "Form Kit" or "Newborn Screening Form Kit" is a FDA approved (or licensed) filter paper kit bearing a stamped lot number that has been approved by the Commissioner of Health. For an example of a FDA approved kit, see Appendix A, Oklahoma Health Department (OHD) Form Kit #450. "Galactosemia" means an inherited disease caused by the body's failure to break down galactose due to a defective enzyme function, which if not treated early in life may cause mental retardation or death. "Hemoglobinopathy" means an inherited hemoglobin disorder. "Infant" means a child 6 months of age and under. "Infant's Physician" means the licensed medical or osteopathic physician responsible for the care of the newborn. "Initial Specimen" means the first blood specimen collected subsequent to birth, pursuant to these procedures. "Long-term Follow-up" means follow-up services that begin with diagnosis and treatment and continues throughout the lifespan, including parent education, networking, referral, and case coordination. "Medium-chain acyl coenzyme A dehydrogenase deficiency or "MCAD" means a genetic disorder of fatty acid metabolism. This disorder can cause metabolic crisis when an infant/child fasts. This crisis can lead to seizures, failure to breathbreathe, cardiac arrest and death. Treatment is effective by preventing fasting. "Newborn" means an infant 30 days of age and under.

"Newborn Screening" or "newborn screening tests" means screening infants for the disorders of phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell diseases, and after June 30, 2004, upon completion of validation studies and establishment of short-term follow-up services, screening infants for cystic fibrosis, congenital adrenal hyperplasia, and medium-chain acyl coenzyme A dehydrogenase deficiency (MCAD), and after October 1, 2007, upon completion of validation studies and establishment of short-term follow-up services, biotinidase deficiency, amino acid disorders, fatty acid oxidation disorders, and organic acid disorders detectable via the Department's laboratory technology utilized in newborn screening and approved by the Commissioner of Health. "Newborn Screening Laboratory" means a laboratory operated by the Department or a laboratory certified by the Department to conduct the tests and carry out the follow-up required by these procedures. "Newborn Screening Program" refers to the Public Health Laboratory and Family Health Services Short-term Follow-up Program at the Oklahoma State Department of Health. "Newborn Screening Program Coordinator" refers to the coordinator of the Family Health Services Short-term Followup Program at the Oklahoma State Department of Health. "Organic Acid Disorders" refers to a group of inherited metabolic conditions in which the body is unable to metabolize or process organic acids properly. Each organic acid disorder is associated with a specific enzyme deficiency that causes the accumulation of organic acids in blood and urine. The accumulated compounds or their metabolites are toxic, resulting in the clinical features of these disorders including mental retardation and death. "Pediatric Sub-Specialist" means a physician licensed in Oklahoma, board certified in pediatrics and board certified in a pediatric sub-specialty of pediatric endocrinology, pediatric pulmonology, or pediatric hematology; or a physician licensed in Oklahoma, board certified in pediatrics whose primary area of practice is pediatric endocrinology, pediatric hematology, pediatric pulmonology, or metabolic specialist. "Phenylketonuria" or "PKU" means an inherited disease caused by the body's failure to convert the amino acid phenylalanine to tyrosine due to defective enzyme function, which if not treated early in life, causes mental retardation. "Planned Health Care Provider" or "Medical Home" means the health care provider who will be providing health care for the infant after discharge from the hospital. "Premature Infant" means an infant weighing less than 2500 grams or any live birth before the thirty-seventh week of gestation. "Repeat Specimen" means an additional newborn screening specimen to be collected after the initial specimen. "Satisfactory Specimen" means a specimen collected using a single form kit which is suitable in both blood quantity and quality to perform screening for phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell disease, cystic fibrosis, congenital adrenal hyperplasia, and medium-chain acyl coenzyme A dehydrogenase deficiency (MCAD), and after October 1, 2007, upon completion of validation studies and establishment of short-term follow-up services, biotinidase deficiency, amino acid disorders, fatty acid oxidation disorders, and organic acid disorders detectable via the Department's laboratory technology utilized in newborn screening and approved by the Commissioner of Health. All requested demographic information on the form kit must be completed. Federal CLIA '88 regulations require that the form kit's laboratory requisition contain sufficient patient data that must include patient's name, date of birth, sex, date of collection, test(s) to be performed, and complete name and address of person requesting the test. "Screened" means a specimen that has been collected and tested on an infant less than 6 months of age. "Screening" means a test to sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. "Short-term Follow-up" includes services provided by the Department and the health care provider that begins when the laboratory reports an abnormal or unsatisfactory screen result and

ends with a diagnosis of normal, lost (repeat testing not achieved), or affected with appropriate treatment and referral has been initiated. "Sick Infant" means an infant with any condition or episode marked by pronounced deviation from the normal healthy state; illness. "Sickle Cell Disease" means an inherited disease caused by abnormal hemoglobin(s) which if not treated early in life may result in severe illness, mental retardation or death (one variation is commonly referred to as sickle cell anemia). "Specimen" means blood collected on the filter paper Newborn Screening Form Kit. "Submitter" means a hospital, other facility, or physician submitting a Newborn Screening specimen. "Transfer" means release of the newborn from care and custody from one licensed health facility to another. "Unsatisfactory Specimen" means a specimen which is not collected on a form kit and/or is not suitable in blood quantity and quality to perform screening for phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell disease, cystic fibrosis, congenital adrenal hyperplasia, and medium-chain acyl coenzyme A dehydrogenase deficiency (MCAD), and after October 1, 2007, upon completion of validation studies and establishment of short-term follow-up services, biotinidase deficiency, amino acid disorders, fatty acid oxidation disorders, and organic acid disorders detectable via the Department's laboratory technology utilized in newborn screening and approved by the Commissioner of Health and/or Federal CLIA '88 regulations are not followed and the form kit's laboratory requisition does not include patient's name, date of birth, sex, date of collection, test(s) to be performed, and complete name and address of person requesting test. B.

STATE MARKET PLAN ENHANCEMENTS -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services. 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Depending on the member's benefit plan, some members may have coverage for dependents, including grandchildren for medical coverage which includes maternity care. Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefit (SOB) to determine coverage eligibility. For Bolded Items in Cover and Not Covered Sections -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services 1.

Prenatal and postnatal care must be provided by a Plan Provider. Note: Refer to the member’s EOC/SOB to determine coverage for midwife services a. Examples include, but are not limited to: 1) Prenatal office visits 2) Postnatal (after delivery) office visits up to 6 weeks post-delivery Note: See Section A for newborn screening

3) 4)

2.

D.

Outpatient (office visit) physician services Screening and diagnostic laboratory and radiological procedures, including but not limited to: a) Alpha fetoprotein blood testing (Please see above section A for more information regarding prenatal screening) b) Fetal fibronectin enzyme immunoassay for women symptomatic for pre-term birth (1) Symptomatic pregnancy between 24 and 34 weeks, especially when tocolytic therapy is initiated (2) Minimal cervical dilation (< 3 cm) 5) Related genetic testing and counseling for prenatal diagnosis of congenital disorders of the unborn child. See Genetic Testing policy. Also see Medial Management Guideline: Genetic Testing (click Internal, Provider Portal or Member). 6) Educational materials for individual needs provided in physician's office Complete inpatient maternity care, including but not limited to: a. Complete inpatient hospital care b. Labor and delivery room care, treatment and services c. Delivery by either normal/vaginal or Cesarean-section (C-Section) d. Treatment of a miscarriage and complications of pregnancy or childbirth e. Physician services (visits) related to all medically necessary inpatient maternity care, treatment and services f. All medically necessary ancillary services related to inpatient maternity care, treatment and services, including but not limited to: 1) Diagnostic laboratory and/or radiologic procedures g. Circumcision 1) For male newborns performed at the hospital prior to hospital discharge 2) For male newborns performed after hospital discharge when: a) Circumcision is delayed by the physician at the time of hospitalization. Unless the delay is for a medical reason, the circumcision will be covered after discharge only through the twenty-eight (28) day neonatal period. b) Medically inappropriate to circumcise at birth due to medical reasons (e.g., prematurity, congenital deformity, etc.). The circumcision must be postponed and offered to the parent(s) when the infant's physician determines it is medically safe and only up to a maximum age of six (6) months. Note: Requests for circumcision of members older than 6 months must be reviewed for medical necessity by a UnitedHealthcare Medical Director or designee.

NOT COVERED For Bolded Items in Cover and Not Covered Sections -For information related to those items covered on or after 08/01/12 under the Expanded Women’s Preventive Health Mandate, please refer to the Medical Management Guideline: Preventive Care Services 1.

2. 3.

Non-medically indicated diagnostic testing such as: a. Any procedure intended solely for sex determination (e.g., ultrasound) b. Blood testing to determine paternity Take home medications and/or supplies, unless member has a supplemental pharmacy benefit Childbirth classes (e.g., Lamaze)

4. 5.

E.

DEFINITIONS 1.

2.

3. 4. F.

Home delivery unless covered under Section A (See Note Above) Maternity services for non- UnitedHealthcare member acting as surrogate to UnitedHealthcare member

Certified Registered Nurse-Midwife: A registered nurse (RN) who has successfully completed a program of study and clinical experience in nurse-midwifery, meeting prescribed guidelines or who has been certified by a recognized organization such as the American College of NurseMidwives. Newborns' and Mothers' Health Protection Act (NMHPA) of 1996: This act established new requirements for plans and insurers with respect to hospital length of stay for childbirth. The NMHPA applies to all group health plans, including self-insured plans, and health insurance coverage. Plans and issuers that do not provide maternity benefits are not required to offer them, and thus are not subject to the provisions of the Act. The Act does not apply to Medicaid or the handful of births covered each year under Medicare. The NMHPA states that the Act is applicable when a beneficiary is receiving the coverage through a group health plan. Group health plan is defined as an employee welfare benefit plan to the extent that the plan provides medical care to employees or their dependents directly or through insurance. The NMHPA does not apply to individuals who are Medicare independent of a group health plan. The Act is not applicable to Medicaid beneficiaries. Postnatal: The period of time occurring or being after birth, generally considered to be 6 weeks. Prenatal: Occurring, existing, or performed before birth.

REFERENCES 1.

Newborns’ and Mothers’ Health Protection Act (NMHPA) of 1996, Title VI

SignatureValue™ Benefit Interpretation Policy SUBJECT:

MEDICAL NECESSITY

TITLE:

Medical Necessity

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 02/01/13

Review Date: 7/12/01, 6/18/03, 10/20/05, 8/28/07, 9/25/08, 12/16/09, 2/16/11, 12/20/11, 12/27/12

Policy Number: M-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

An intervention will be covered under UnitedHealthcare if it is an otherwise covered category of service, not specifically excluded, and medically necessary. An intervention may be medically indicated yet not be a covered benefit or meet the definition of medical necessity. An intervention is medically necessary if, as recommended by the treating physician and determined by the medical director of UnitedHealthcare or the Participating Medical Group, it is (all of the following): a.

A health intervention for the purpose of treating a medical condition

b.

The most appropriate supply or level of service, considering potential benefits and harms to the member

c.

Known to be effective in treating the medical condition. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion. For new interventions, effectiveness is determined by scientific evidence.

d.

If more than one health intervention meets the requirements of a, b and c above, furnished in the most cost-effective manner which may be provided safely and effectively to the member.

D.

NOT COVERED

E.

DEFINITIONS

F.

1.

Cost Effective: An intervention is considered cost effective if the benefits and harms relative to costs represent an economically efficient use of resources for patients with this condition. In the application of this criterion to an individual case, the characteristics of the individual patient shall be determinative.

2.

Effective: The intervention is considered effective if it can reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

3.

Health Intervention: An item or service delivered or undertaken primarily to treat (that is, prevent, diagnose, detect, treat, or palliate) a medical condition or to maintain or restore functional ability. A health intervention is defined by the intervention itself, the medical condition and the patient indications for which it is being applied.

4.

Medical Condition: A disease, illness, injury, genetic or congenital defect, pregnancy, or a biological condition that lies outside the range of normal, age appropriate human variation.

5.

New Intervention: An intervention that is not yet in widespread use for the medical condition and patient indications being considered. New interventions for which clinical trials have not been conducted because of epidemiological reasons (e.g., rare or new diseases or orphan populations) shall be evaluated on the basis of professional standards of care. If professional standards of care do not exist, or are outdated or contradictory, decisions about such new interventions should be based on convincing expert opinion.

6.

Scientific Evidence: Consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available, observational studies that suggest a causal relationship between the intervention and health outcomes can be used. Such studies do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases. For existing interventions, the scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care should be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about existing interventions should be based on expert opinion. Giving priority to scientific evidence does not mean that coverage of existing interventions should be denied in the absence of conclusive scientific evidence. Existing interventions can meet the definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of such standards, convincing expert opinion.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

MEDICATIONS

TITLE:

Medications(Oral, Infusion, Injectable) and Off-label Drug Use

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 3/24/05

Effective Date: 4/24/05

Review Date: 10/20/05, 5/10/07, 2/14/08, 4/15/09, 4/21/10, 04/26/12, 04/25/13

Policy Number: M-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

OAC 365:40-5-21 - Supplemental health care services Supplemental health care services of an HMO may include the following: (1) Corrective appliances and artificial aids. (2) Eyeglasses and hearing care not included as a basic health care service. (3) Dental services. (4) Mental health services not included as a basic health care service. (5) Long-term physical therapy and rehabilitative services. (6) Cosmetic surgery, unless medically necessary. (7) Prescribed drugs and medicines incidental to outpatient care. Supplemental coverage for prescription drugs shall also provide coverage of off-label uses of prescription drugs used in the treatment of cancer or the study of oncology. Coverage shall include the approval of oncology (chemotherapeutic) drugs for off-label indications when used for malignant disease, when the safety and effectiveness of use for this indication has been recommended, supported and demonstrated by at least one controlled clinical trial published in a nationally recognized peer reviewed journal or when at least one of the standard pharmacy compendia (United States Pharmacopoeia Dispensing Information [USPDI], American Society of Health-System Pharmacists Drug Information [AHFS Drug Information] or American Medical Association Drug Evaluations [AMADE]) lists the drug to be accepted as safe and effective for this indication. This will not include the off-label use of these agents in the treatment of non-malignant disease. (8) Ambulance services, unless medically necessary. (9) Care for military service connected disabilities for which the enrollee is legally entitled to services and for which facilities are reasonably available to this enrollee. (10) Care for conditions that State or local law requires be treated in a public facility. (11) Custodial or domiciliary care. (12) Experimental medical, surgical, or other experimental health care procedures, unless approved as a basic health care service by the policy making body of the HMO. (13) Personal or comfort items and private rooms, unless necessary during inpatient hospitalization. (14) Whole blood and blood plasma.

(15) Durable medical equipment for home use (such as wheel chairs, surgical beds, respirators, dialysis and machines). (16) Health care services which are unusual or infrequently provided and not necessary for the protection of individual health, as approved by the Department upon application by the HMO. "Unusual or infrequently used health services" means those health services which are projected to involve fewer that 1 percent (1%) of the encounters per year for the entire HMO enrollment, or, those health services the provision of which, given the enrollment projection of the HMO and generally accepted staffing patterns, is projected will require less than 0.25 full time equivalent health professionals. B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Notes: • Members may have supplemental outpatient prescription drug benefit. Please refer to the Member’s EOC/SOB or contact the Customer Service Department to determine coverage eligibility. • For coverage of clinical trials, refer to the Cancer Clinical Trials policy. • For coverage of chemotherapy drugs, refer to the Chemotherapy policy. • For medically necessity definition, refer to the Medical Necessity policy. 1.

2.

Injectable drugs a. Infusion therapy when furnished as part of a treatment plan and authorized by the member’s contracting/participating PMG/provider Note: The infusions must be administered in the member's home, participating/contracting Physician's office ambulatory/outpatient infusion center or in an institution such as board and care, custodial care, or assisted living facility. b. Outpatient injectable medications when administered incidental to the physician’s office visit and when not otherwise limited or excluded Note: Outpatient injectable medications must be obtained through a participating/contracting provider or through the member’s participating/contracting medical group and may require prior-authorization. c. Self-injectable medications when prescribed by a participating/contracting provider as authorized by the member’s contracting/participating medical group or UnitedHealthcare. Note: Self-injectable medications must be obtained through a participating/contracting provider or through the member's participating/contracting medical group or UnitedHealthcare designated pharmacy/specialty injectable vendor, and may require priorauthorization. Off label drug use, including self-injectable drugs, only when all of the following criteria are met: a. The drug is approved by the FDA (for label usage); b. The drug is prescribed by a participating/contracting provider for the treatment of a life-

c. d. e.

f.

D.

NOT COVERED 1.

2.

3. 4.

5.

E.

Outpatient drugs and prescription medications except when covered under the member’s Supplemental Outpatient prescription benefit. Refer to the member’s EOC/SOB or contact the Customer Service Department to determine coverage eligibility. Insulin except when covered under the member’s Supplemental Outpatient Prescription drug benefit. Refer to the Covered Person’s COC/SOB or contact the Customer Service Department to determine coverage eligibility. (Note: See Diabetic Management and Supplies policy for coverage of insulin used with insulin pump.) Off-label use of medication not meeting the criteria in Section C Medications for elective enhancements such as those used for elective improvements, alterations, enhancements, augmentation, or genetic manipulation related hair growth, aging, athletic performance, intelligence, height, weight, or cosmetic appearance Medications for the treatment of sexual dysfunction or inadequacy except testosterone injections for documented low testosterone levels

DEFINITIONS 1.

2. 3. 4. 5.

F.

threatening condition or for a chronic and seriously debilitating condition; The drug is medically necessary to treat the condition; The patient has failed, is intolerant of, or has contraindications to standard therapies; The drug has been recognized for treatment of the life-threatening or chronic and seriously debilitating condition by one of the following: The American Hospital Formulary Service Drug Information, DRUGDEX System by Micromedex, The United States Pharmacopoeia Dispensing Information or in two articles from major peer-reviewed medical journals that present data supporting the proposed Off-Label Drug Use or uses as generally safe and effective unless there is clear and convincing contradictory evidence presented in a major peer reviewed medical journal. The drug is covered under the member’s injectable drug benefit described in the outpatient benefits section of the member’s EOC

FDA Approved Drug: A drug that has received final marketing approval by the Food & Drug Administration (FDA) and, as a part of its labeling, contains its recommended uses and dosages as well as adverse reactions and recommended precautions in using it. Infusion therapy: Refers to the therapeutic administration of drugs or other prepared or compounded substances by the intravenous route. Off Label Use of a Drug: A use that is not included as an indication on the drug's label as supported by the FDA. Outpatient Injectable Medications: Include those drugs or preparations which are not usually self-administered, and which are given by the intramuscular or subcutaneous route Self-injectable medications: Drugs which are either generally self-administered by intramuscular injection at a frequency of one or more times per week, or which are generally self-administered by the subcutaneous route.

REFERENCES

1.

HMO Evidence of Coverage 2005

SignatureValue™ Benefit Interpretation Policy SUBJECT:

MENTAL HEALTH

TITLE:

Inpatient Mental Health

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 9/19/02, 12/18/03, 12/5/05, 11/6/07, 10/31/08, 11/28/08, 2/18/09, 2/17/10, 02/23/12, 02/28/13

Policy Number: M-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS FEDERAL: 1. H. R. 1424 Emergency Economic Stabilization Act of 2008 SEC. 512. MENTAL HEALTH PARITY. (a) AMENDMENTS TO ERISA.—Section 712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a) is amended— (1) in subsection (a), by adding at the end the following: (3) FINANCIAL REQUIREMENTS AND TREATMENT LIMITATIONS.— (A) IN GENERAL.—In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that— (i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and (ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits. 1.

2.

Department of Insurance Title 36, Section 6060.10(3): Requires coverage of inpatient and outpatient services for severe mental illness: schizophrenia, bipolar/manic depressive disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder and schizoaffective disorder. 43A O.S. 2001, Sections 1-103 is amended to read as follows (SB 2076 - The amendments (language in bold) to 43A O.S. 2001, Sections 1-103 take effect November 1, 2008, and apply to group health insurance policies issued or renewed on or after November 1, 2008): 3. "Mental illness" means a substantial disorder of thought, mood, perception, psychological

orientation or memory that significantly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life… …7. "Facility" means any hospital, school, building, house or retreat, authorized by law to have the care, treatment or custody of an individual with mental illness, or drug or alcohol dependency, gambling addiction, eating disorders, or an individual receiving methadone treatment for dependency purposes only, including, but not limited to, public or private hospitals, community mental health centers, clinics, satellites or facilities; provided that facility shall not mean a child guidance center operated by the State Department of Health; …11. "Licensed mental health professional" means: a. a psychiatrist who is a diplomate of the American Board of Psychiatry and Neurology, b. a physician licensed pursuant to Section 480 et seq. or Section 620 et seq. of Title 59 of the Oklahoma Statutes who has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions, c. a clinical psychologist who is duly licensed to practice by the State Board of Examiners of Psychologists, d. a professional counselor licensed pursuant to Section 1901 et seq. of Title 59 of the Oklahoma Statutes, e. a person licensed as a clinical social worker pursuant to the provisions of the Social Worker’s Licensing Act, f. a licensed marital and family therapist as defined in Section 1925.1 et seq. of Title 59 of the Oklahoma Statutes, g. a licensed behavioral practitioner as defined in Section 1930 et seq. of Title 59 of the Oklahoma Statutes, or h. an advanced practice nurse as defined in Section 567.1 et seq. of Title 59 of the Oklahoma Statutes specializing in mental health, or i. a physician’s assistant who is licensed in good standing in this state and has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions;… …13. a. "Person requiring treatment" means: (1) a person who because of a mental illness of the person represents a risk of harm to self or others, or (2) a person who is a drug- or alcohol-dependent person and who as a result of dependency represents a risk of harm to self or others. b. Unless a person also meets the criteria established in subparagraph a of this paragraph, person requiring treatment shall not mean: (1) a person whose mental processes have been weakened or impaired by reason of advanced years, dementia, or Alzheimer’s disease, (2) a mentally retarded or developmentally disabled person as defined in Title 10 of the Oklahoma Statutes, (3) a person with seizure disorder, (4) a person with a traumatic brain injury, or (5) a person who is homeless;

17. "Individualized treatment plan" means a proposal developed during the stay of an individual in a facility, under the provisions of this title, which is specifically tailored to the treatment needs of the individual. Each plan shall clearly include the following:

a.

a statement of treatment goals or objectives, based upon and related to a clinical evaluation, which can be reasonably achieved within a designated time interval, b. treatment methods and procedures to be used to obtain these goals, which methods and procedures are related to each of these goals and which include specific prognosis for achieving each of these goals, c. identification of the types of professional personnel who will carry out the treatment procedures, including appropriate medical or other professional involvement by a physician or other health professional properly qualified to fulfill legal requirements mandated under state and federal law, d. documentation of involvement by the individual receiving treatment and, if applicable, the accordance of the individual with the treatment plan, and e. a statement attesting that the executive director of the facility or clinical director has made a reasonable effort to meet the plan's individualized treatment goals in the least restrictive environment possible closest to the home community of the individual; 18. "Risk of harm to self or others" means: a. a substantial risk of immediate physical harm to self as manifested by evidence or serious threats of or attempts at suicide or other significant self-inflicted bodily harm, b. a substantial risk of immediate physical harm to another person or persons as manifested by evidence of violent behavior directed toward another person or persons, c. having placed another person or persons in a reasonable fear of violent behavior directed towards such person or persons or serious physical harm to them as manifested by serious and immediate threats, d. there exists a substantial risk that without immediate intervention severe impairment or injury will result to the person alleged to be a person requiring treatment, or e. a substantial risk of immediate serious physical injury to self, or immediate death, as manifested by evidence that the person is unable to provide for and is not providing for the basic physical needs of the person and that appropriate provision for those needs cannot be made immediately available in the community. Unless a person also meets the criteria established in subparagraphs a, b, c, d, or e of this paragraph, “risk of harm to self or others” does not mean a person who is homeless; and 19. “Telemedicine” means the practice of health care delivery, diagnosis, consultation, evaluation, treatment, transfer of medical data, or exchange of medical education information by means of audio, video, or data communications. Telemedicine uses audio and video multimedia telecommunication equipment which permits two-way real-time communication between a health care practitioner and a patient who are not in the same physical location. Telemedicine shall not include consultation provided by telephone or facsimile machine. The complete text can be accessed at http://webserver1.lsb.state.ok.us/200708bills/SB/SB2076_SFLR.RTF B.

STATE MARKET PLAN ENHANCEMENTS 1.

Some members may have additional inpatient mental health benefits. For member specific coverage and limitations for inpatient mental health benefit, refer to the member’s EOC/SOB or contact the Customer Service Department.

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless mandated by State or Federal law and/or covered as Market Plan Enhancements (See Sections A & B) Also see Detoxification: Chemical Dependency/Substance Abuse policy

D.

NOT COVERED

E.

DEFINITIONS 1.

F.

Mental Health Services: Mental health services can be provided on an inpatient and outpatient basis and include treatable mental disorders such as severe mental illness and stress related conditions. These disorders affect the member’s ability to cope with the requirements of daily living.

REFERENCES 1.

Mental Health Parity Act of 1996

SignatureValue™ Benefit Interpretation Policy SUBJECT:

MENTAL HEALTH

TITLE:

Outpatient Mental Health

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 5/6/03, 5/5/04, 12/5/05, 11/6/07, 10/31/08, 11/28/08, 2/18/09, 2/17/10, 02/28/13

Policy Number: M-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS FEDERAL: 1. H. R. 1424 Emergency Economic Stabilization Act of 2008 SEC. 512. MENTAL HEALTH PARITY. (a) AMENDMENTS TO ERISA.—Section 712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a) is amended— (1) in subsection (a), by adding at the end the following: (3) FINANCIAL REQUIREMENTS AND TREATMENT LIMITATIONS.— (A) IN GENERAL.—In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that— (i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and (ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits. 1.

2.

3.

Oklahoma Department of Insurance Title 36 Section 6060.10 (3): Requires coverage of inpatient and outpatient services for severe mental illness: schizophrenia, bipolar/manic depressive disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder and schizoaffective disorder. Oklahoma Administrative Code 365:40-5-20 (6): Twenty outpatient visits per enrollee per year, as may be necessary and appropriate for short-term evaluative or crisis intervention mental health services, or both. 43A O.S. 2001, Sections 1-103 is amended to read as follows (SB 2076 - The amendments (language in bold) to 43A O.S. 2001, Sections 1-103 take effect November 1, 2008, and apply to group health insurance policies issued or renewed on or after November 1, 2008):

3. "Mental illness" means a substantial disorder of thought, mood, perception, psychological orientation or memory that significantly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life… …7. "Facility" means any hospital, school, building, house or retreat, authorized by law to have the care, treatment or custody of an individual with mental illness, or drug or alcohol dependency, gambling addiction, eating disorders, or an individual receiving methadone treatment for dependency purposes only, including, but not limited to, public or private hospitals, community mental health centers, clinics, satellites or facilities; provided that facility shall not mean a child guidance center operated by the State Department of Health; …11. "Licensed mental health professional" means: a. a psychiatrist who is a diplomate of the American Board of Psychiatry and Neurology, b. a physician licensed pursuant to Section 480 et seq. or Section 620 et seq. of Title 59 of the Oklahoma Statutes who has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions, c. a clinical psychologist who is duly licensed to practice by the State Board of Examiners of Psychologists, d. a professional counselor licensed pursuant to Section 1901 et seq. of Title 59 of the Oklahoma Statutes, e. a person licensed as a clinical social worker pursuant to the provisions of the Social Worker’s Licensing Act, f. a licensed marital and family therapist as defined in Section 1925.1 et seq. of Title 59 of the Oklahoma Statutes, g. a licensed behavioral practitioner as defined in Section 1930 et seq. of Title 59 of the Oklahoma Statutes, or h. an advanced practice nurse as defined in Section 567.1 et seq. of Title 59 of the Oklahoma Statutes specializing in mental health, or i. a physician’s assistant who is licensed in good standing in this state and has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions;… …13. a. "Person requiring treatment" means: (1) a person who because of a mental illness of the person represents a risk of harm to self or others, or (2) a person who is a drug- or alcohol-dependent person and who as a result of dependency represents a risk of harm to self or others. b. Unless a person also meets the criteria established in subparagraph a of this paragraph, person requiring treatment shall not mean: (1) a person whose mental processes have been weakened or impaired by reason of advanced years, dementia, or Alzheimer’s disease, (2) a mentally retarded or developmentally disabled person as defined in Title 10 of the Oklahoma Statutes, (3) a person with seizure disorder, (4) a person with a traumatic brain injury, or (5) a person who is homeless;

17. "Individualized treatment plan" means a proposal developed during the stay of an individual in a facility, under the provisions of this title, which is specifically tailored to the treatment needs of the individual. Each plan shall clearly include the following:

a.

a statement of treatment goals or objectives, based upon and related to a clinical evaluation, which can be reasonably achieved within a designated time interval, b. treatment methods and procedures to be used to obtain these goals, which methods and procedures are related to each of these goals and which include specific prognosis for achieving each of these goals, c. identification of the types of professional personnel who will carry out the treatment procedures, including appropriate medical or other professional involvement by a physician or other health professional properly qualified to fulfill legal requirements mandated under state and federal law, d. documentation of involvement by the individual receiving treatment and, if applicable, the accordance of the individual with the treatment plan, and e. a statement attesting that the executive director of the facility or clinical director has made a reasonable effort to meet the plan's individualized treatment goals in the least restrictive environment possible closest to the home community of the individual; 18. "Risk of harm to self or others" means: a. a substantial risk of immediate physical harm to self as manifested by evidence or serious threats of or attempts at suicide or other significant selfinflicted bodily harm, b. a substantial risk of immediate physical harm to another person or persons as manifested by evidence of violent behavior directed toward another person or persons, c. having placed another person or persons in a reasonable fear of violent behavior directed towards such person or persons or serious physical harm to them as manifested by serious and immediate threats, d. there exists a substantial risk that without immediate intervention severe impairment or injury will result to the person alleged to be a person requiring treatment, or e. a substantial risk of immediate serious physical injury to self, or immediate death, as manifested by evidence that the person is unable to provide for and is not providing for the basic physical needs of the person and that appropriate provision for those needs cannot be made immediately available in the community. Unless a person also meets the criteria established in subparagraphs a, b, c, d, or e of this paragraph, “risk of harm to self or others” does not mean a person who is homeless; and 19. “Telemedicine” means the practice of health care delivery, diagnosis, consultation, evaluation, treatment, transfer of medical data, or exchange of medical education information by means of audio, video, or data communications. Telemedicine uses audio and video multimedia telecommunication equipment which permits two-way real-time communication between a health care practitioner and a patient who are not in the same physical location. Telemedicine shall not include consultation provided by telephone or facsimile machine. The complete text can be accessed at http://webserver1.lsb.state.ok.us/200708bills/SB/SB2076_SFLR.RTF B.

STATE MARKET PLAN ENHANCEMENTS 1.

Some members may have additional outpatient mental health benefits. For member specific coverage and limitations for outpatient mental health benefit, refer to the member’s EOC/SOB or

contact the Customer Service Department. C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Outpatient visits for medical necessity and as appropriate for short-term evaluation and/or crisis intervention (see Medical Necessity policy) 2. Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients 3. Drugs and biologicals furnished to psychiatric outpatients, only if member has supplemental prescription benefit 4. Crisis intervention and emergency treatment, including evaluation and referrals a. Any related medical care follows under the medical benefit (e.g., medical care of a member who has self-inflicted injury or who has attempted suicide) (Note: Applies to Small Employer Groups only, refer to the member's EOC/SOB for specific number of visits covered per calendar year) 5. ECT (electroconvulsive therapy) for management of depression (See member’s EOC/SOB for specific coverage and limitations) 6. Routine laboratory testing for therapeutic medication level, e.g., serum lithium level in the treatment of Bipolar Disorder 7. Initial psychological testing if medically indicated as determined by the participating/contracting psychologist/psychiatrist to further evaluate a questionable diagnosis Also see Detoxification: Chemical Dependency/Substance Abuse policy D.

NOT COVERED 1.

E.

DEFINITIONS 1. 2.

F.

Examples of outpatient mental health benefits that are not covered include, but are not limited to: a. Meals and transportation b. Activity therapies, group activities or other services and programs that are primarily recreational or diversional activities c. Geriatric day care d. Outpatient hospital psychiatric programs consisting only of psychosocial activities e. Outpatient prescription drugs, unless the member has supplemental prescription benefit f. Light therapy box for seasonal affective disorder (SAD) (see DME, Prosthetics, Corrective Appliances and Medical Supplies Grid)

Crisis Intervention: Short-term, medically necessary treatment required to restore a member in crisis to the pre-crisis level of function. Mental Health: Mental health services can be provided on an inpatient and outpatient basis and include treatable mental disorders such as severe mental illness and stress related conditions. These disorders affect the member’s ability to cope with the requirements of daily living.

REFERENCES 1.

Mental Health Parity Act of 1996

SignatureValue™ Benefit Interpretation Policy SUBJECT:

Neuropsychological Testing

TITLE:

Neuropsychological Testing

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/23/04

Effective Date: 7/23/04

Review Date: 5/4/06, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 6/27/13

Policy Number: N-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A. FEDERAL/STATE MANDATED REGULATIONS 1.

None

B. STATE MARKET PLAN ENHANCEMENTS 1.

None

C. COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Neuropsychological Testing (NPT)/psychometrics and consultation when assessment is needed to: a. Diagnose or manage the following conditions: 1) Dementia, e.g., Alzheimer’s disease 2) HIV related encephalopathy 3) Multiple sclerosis 4) Epilepsy (pre-surgical evaluation) 5) Parkinson’s disease b. To develop and/or evaluate a rehabilitation treatment plan for the following conditions: 1) Traumatic brain injury 2) Cerebrovascular disease Note: Neuropsychological testing solely for the evaluation of serious psychiatric illness or substance abuse may be covered under Mental Health Benefits. Contact the Customer Services Department for benefit eligibility. See Medical Management Guideline: Neuropsychological Testing (click Internal, Provider Portal or Member).

D. NOT COVERED 1. 2. 3. 4. 5. 6.

Forensic applications in cases of litigation Work related toxicity Routine screenings Educational or vocational evaluation Self-administered or self-scored inventories Neuropsychological testing for attention deficit hyperactivity disorder (ADHD) except for neurologically complex cases (e.g., epilepsy)

E. DEFINITIONS

F.

REFERENCES 1.

American Academy of Neurology. Assessment: Neuropsychological Testing of Adults. Consideration for Neurologist, 1996.

SignatureValue™ Benefit Interpretation Policy SUBJECT:

NON-COVERED SERVICES

TITLE:

Services/Complications Related to Non-covered Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 1/7/00

Effective Date: 10/1/00

Review Date: 12/5/02, 1/14/04, 5/4/06, 7/14/06, 5/22/08, 8/14/08, 9/25/08, 10/28/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: N-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

IMPORTANT NOTE: The following apply only to members whose group contracts have been issued, amended, or renewed after January 1, 2006. A.

FEDERAL/STATE MANDATED REGULATIONS 1.

Oklahoma Statutes §6060.4a of Title 36 (effective 01/01/2009) SECTION 1. NEW LAW A new section of law to be codified in the Oklahoma Statutes as Section 6060.4a of Title 36, unless there is created a duplication in numbering, reads as follows: No health benefit plan, including, but not limited to, the State and Education Employees Group Health Insurance Plan, that is offered, issued or renewed in the state on or after January 1, 2009, shall exclude otherwise allowable claims which occur in conjunction with the arrest or pretrial detention of the policyholder prior to adjudication of guilt and sentencing to incarceration of such policyholder. The reimbursement rate for out-of-network claims for these services shall be set at the current Medicare rate. SECTION 1. This act shall become effective November 1, 2008.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless covered under Section A or B

D.

NOT COVERED 1.

UnitedHealthcare does not cover the services or costs associated with a service that is not a covered service under the Member’s UnitedHealthcare Health Plan including but not limited to cosmetic surgery, bariatric surgery, and experimental and investigational procedures. This means that UnitedHealthcare will not cover medical, hospital, and follow-up care or complications associated with or arising from a non-covered service when: a) the services or expenses are incurred in preparation for a non-covered service b) the complications or services are associated with non-covered services provided by another health plan or insurance company even if the service was covered under the prior plan c) the complications or services are associated with non-covered services the member paid for outof-pocket (e.g., cosmetic surgery, bariatric surgery, experimental and investigational procedures) Note: Please see Emergency and Urgent Services policy for covered emergent and urgent services. 2. Treatment for an injury or condition sustained as a result of the Member's commission of a felony or attempt to commit a felony is not covered. This exclusion does not apply to injuries or conditions resulting from an act of domestic violence, or a physical or mental medical condition. 3. Services performed by immediate relatives or members of Member’s household. E.

DEFINITIONS

F.

REFERENCES 1.

MCO Combined Evidence EOC & Disclosure Form

SignatureValue™ Benefit Interpretation Policy SUBJECT:

NUTRITIONAL THERAPY

TITLE:

Enteral and Oral Nutritional Therapy

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 5/3/01, 6/18/03, 10/20/05, 8/28/07, 9/25/08, 9/1/09, 9/2/10, 4/19/11, 8/16/11, 08/23/12, 08/22/13

Policy Number: N-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Enteral nutritional therapy, including formula, accessories and supplies, is covered under the medical benefit when all of the following criteria are met: a. The member exhibits one of the following conditions: 1) Permanent disease or non-function of the structures that would normally permit food to reach the digestive tract 2) Disease of the small bowel that prevents digestion and absorption of an oral diet, either of which requires tube feedings in order to maintain weight and strength b. The member is in a skilled nursing facility. c. The therapy is the sole source of caloric intake (i.e., 100% of the member's nutritional source) (Note: When the member is no longer receiving skilled nursing facility services, the formula is not covered. The pump and pump-related accessories and supplies necessary to deliver the feeding/formula may be covered as DME and are subject to the applicable benefit).

D.

NOT COVERED 1. 2. 3. 4. 5. 6.

E.

DEFINITIONS 1. 2. 3.

4.

F.

Non-prescription oral formula Food products naturally low in protein Baby foods, groceries or blenderized foods Formulas, food, vitamins, herbs and dietary supplements Formula or food for the treatment of Phenylketonuria or other metabolic diseases Enteral formula or medical food when the member is not receiving medically necessary skilled home health visits or skilled nursing facility services or skilled therapy visits (Note: Home health or skilled nursing services are not considered medically necessary if the primary purpose is to monitor enteral feedings.)

Dysphagia: A condition in which the action of swallowing is either difficult to perform, painful, or in which swallowed material seems to be held up in its passage to the stomach. Enteral Nutrition: Provision of nutritional requirements through a tube into the stomach. It may be administered by syringe, gravity, or pump. Phenylketonuria (PKU) Treatment: Diagnosis and treatment of PKU including formula and special food products necessary for the treatment that are part of a diet prescribed by the treating physician Permanence: For the purposes of this policy, permanence does not require a determination that there is no possibility that the member’s condition may improve sometime in the future. If the physician’s opinion is that the condition is of long and indefinite duration (ordinarily at least 3 months), then the qualifier of permanent is met.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

NUTRITIONAL THERAPY

TITLE:

Parenteral Nutritional Therapy

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 06/18/03, 10/6/04, 5/4/06, 8/28/07, 9/25/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: N-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Daily parenteral nutrition is covered under the following circumstances: a. Member requires bowel rest, such as for the treatment of pancreatitis, severe enteritis or the presence of a fistula prohibiting placement of a feeding tube b. Member exhibits one of the following conditions: 1) Severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition 2) Recent (within the past 3 months) massive small bowel resection resulting in severe nutritional deficiency in spite of adequate oral intake 3) Severe Short Bowel Syndrome 4) Complete mechanical small bowel obstruction for which surgery is not an option 5) Significant malnourishment

a)

D.

10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl and has very severe fat malabsorption (fecal fat exceeds 50% of oral/enteral intake on a diet of at least 50 gm of fat/day as measured by a standard 72 hour fecal fat test), or b) 10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl and has a severe motility disturbance of the small intestine and/or stomach which is unresponsive to prokinetic medication and is demonstrated either (1) scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach the right colon by 6 hours following ingestion), or (2) radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following administration) Note: These studies must be performed when the patient is not acutely ill and is not on any medication which would decrease bowel motility. c. For members receiving parenteral nutrition as a part of renal dialysis (intradialytic parenteral nutrition [IDPN]) and who meet the following criteria: 1) Inadequate absorption of nutrients to maintain adequate strength and weight 2) Member is not able to be maintained on oral or enteral feedings 3) Member must be given their nutrients through an IV 4) Parenteral nutrition is vital to the nutritional stability of the member and not supplemental to a deficient diet or deficiencies caused by dialysis NOT COVERED 1.

2. 3. 4. E.

Member with a functioning GI tract and whose need for parenteral therapy is only due to: a. A swallowing disorder b. Impaired food intake as a result of a psychological disorder such as depression c. A side effect of a medication d. Renal failure and/or dialysis e. Metabolic or electrolyte disorder Diet modifications and/or use of appetite stimulants and/or medications for treating the cause of malabsorption were not tried first or are working Member has not had a 90-day trial period of tube or enteral feedings where appropriate as determined by the Medical Director or designee Intraperitoneal nutrition (IPN)

DEFINITIONS 1.

2.

3. 4.

Intradialytic Parenteral Nutrition (IDPN): Method whereby nutritional substrates; usually carbohydrate, protein, fat, and required trace elements; are provided to dialysis patients during hemodialysis. The solution is provided intravenously at the time of dialysis. Intraperitoneal nutrition (IPN): Parenteral nutrition solution consisting of amino acids in a standard dialysate solution, which is instilled in the peritoneal cavity one to two times daily for the purpose of improving nutritional status. Amino acids are usually added to produce a final total concentration of 1% amino acid and are compounded by a Registered Pharmacist. Parenteral Therapy: Nutritional support given by means, such as intravenously (IV), other than through the GI tract. Significant Malnourishment: Present in members who have experienced a 10% weight loss over

three months or less and a serum albumin of less than or equal to 3.4 gm/DL. F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

OBESITY

TITLE:

Treatment of Morbid Obesity

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 5/12/00, 3/21/02, 5/6/03, 6/18/03, 3/17/04 , 6/23/04, 5/4/06, 2/14/08, 5/22/08, 06/25/08, 4/13/09, 6/23/09, 4/28/10, 6/22/10, 06/21/11, 12/20/11, 06/28/12, 06/27/2013

Policy Number: O-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

None

STATE MARKET PLAN ENHANCEMENTS 1.

None

Notes: • Some members may have coverage for surgical treatment of morbid obesity (e.g., General Electric and Boeing Corporation). Check the Evidence of Coverage (EOC)/Schedule of Benefits (SOB) to determine benefit eligibility. For members who have coverage for surgical treatment of morbid obesity, the pre-surgical psychological consultations for bariatric surgery are covered under the medical benefit. • For Federal employees, bariatric surgical procedures are covered when medically necessary and preauthorized. Scientifically valid, evidence-based criteria should be used to determine coverage of bariatric surgery, such as the most recent National Institutes of Health (NIH) guidelines, in determining the medical necessity of requests for surgical treatment for morbid obesity. Member must meet all the clinical criteria to qualify for bariatric surgery. C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Some members may have coverage for surgical treatment of morbid obesity (e.g., Federal employees, General Electric and Boeing Corporation). Check the Evidence of Coverage

(EOC)/Schedule of Benefits (SOB) to determine benefit eligibility. 1.

2.

Physician prescribed supplemented fasting with monitoring on a case-by-case basis when weight loss is necessary prior to a surgical procedure to minimize any possible complications and the member's obesity co-exists with a high-risk condition, such as: a.

Cardiac disease

b.

Respiratory disease

c.

Diabetes

d.

Hypertension (high blood pressure)

Physician prescribed supplemental fasting with monitoring on a case by case basis when weight loss is part of a medically necessary treatment plan for hypothyroidism, Cushing's disease or hypothalamic disease. • •

D.

E.

Also see Weight Gain or Weight Loss Programs policy See Medical Management Guidelines: Bariatric Surgery (click Internal, Provider Portal or Member) and Panniculectomy and Body Contouring Procedures (click Internal, Provider Portal or Member)

NOT COVERED 1.

Bariatric surgery (e.g. Open and laparoscopic Roux-en-Y gastric bypass (RYGBP); laparoscopic adjustable gastric banding (LAGB) such as LAP-BAND®, REALIZE™; and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) unless member has the benefit coverage and medical criteria are met. See Sections A, B & C and refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) to determine coverage eligibility.

2.

Treatment of obesity when criteria are not met

3

Supplemented fasting (e.g., Optifast) as a general treatment for obesity, except as indicated above

4.

Nutritional liquid supplements

5.

Weight reduction medications, including diet pills, unless otherwise covered under the supplemental benefit.

DEFINITIONS Lifetime: For Health Plans that have certain benefits with a lifetime maximum, this is the maximum amount of Covered Services that UnitedHealthcare will cover during the entire period of time that the Member is enrolled under the Group Agreement issued to the Employer Group. Any benefit lifetime maximum would only apply if the member is continuously enrolled on the same UHC health plan with the same employer, with only one exception: If a member is enrolled with the same employer under the same UHC health plan contract (e.g. HMO plan) and leaves employment with that employer temporarily (or goes on an extended LOA) and loses their health plan coverage but later returns to the same employer and re-enrolls in the same exact UHC health plan (e.g. HMO plan) then this is the same lifetime. Morbid Obesity: Morbid obesity exists in patients that have a Body Mass Index (BMI) > 40 or a BMI > 35 with co-morbid conditions. BMI is calculated as weight in kilograms per height in meters squared (kg/m2).

Supplemented Fasting: A type of very low calorie weight reduction regimen used to achieve rapid weight loss. The reduced calorie intake is supplemented by a mixture of protein, carbohydrates, vitamins and minerals. F.

REFERENCES Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Heart, Lung and Blood Institute (NIH), June 1998

SignatureValue™ Benefit Interpretation Policy SUBJECT:

OSTEOGENIC/BONE STIMULATION

TITLE:

Osteogenic/Bone Stimulation

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 7/7/00, 11/3/00, 6/18/03, 12/18/03, 5/5/04, 5/4/06, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: O-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern. A.

FEDERAL/STATE MANDATED REGULATIONS None

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

D.

The following are covered when criteria are met. See Medical Management Guidelines: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation for coverage criteria (click Internal, Provider Portal or Member). a. Invasive electrical stimulation b. Non-invasive electrical stimulation c. Non-invasive ultrasonic stimulation

NOT COVERED Osteogenic stimulation that does not meet criteria. See Medical Management Guidelines: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation for coverage criteria (click Internal, Provider Portal or Member).

E.

DEFINITIONS Invasive: Entry into the body by incision or insertion of an instrument. Non-invasive: Not involving penetration of the skin. Osteogenic: Producing bone. Osteogenic Stimulation: Used to promote bone repair with the use of an osteogenic stimulator. Osteogenic Stimulators: Devices that provide electrical stimulation, either invasively or non-invasively, to the bone. Ultrasonic Osteogenic Stimulator: A non-invasive device that emits low intensity, pulsed ultrasound. The ultrasound signal is applied to the skin surface at the fracture location via ultrasound, conductive, coupling gel in order to stimulate fracture healing.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

OSTOMY

TITLE:

Ostomy Supplies

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 1/7/00

Effective Date: 10/1/00

Review Date: 5/3/01, 12/5/02, 1/14/04, 2/16/06, 2/14/08, 4/15/09, 4/21/10, 4/19/11, 04/26/12, 04/25/13

Policy Number: O-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

Refer to Ostomy Supplies Grid. Also see DME, Prosthetics, Corrective Appliances and Medical Supplies policy

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. D.

None unless covered under Section B.

NOT COVERED 1.

Ostomy supplies are not covered unless covered under Section B.

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Ostomy Supplies Grid Market: UnitedHealthcare of Oklahoma, Inc.

Review Date: 12/5/02, 1/14/04, 2/16/06, 12/7/06, 2/14/08, 4/15/09, 4/21/10, 4/19/11, 4/26/12, 04/25/13

ITEM

COVERAGE

Adhesive (e.g. tape, cement, powder, disc, foam pad)

Covered

Adhesive Remover of Solvent (e.g., liquid or wipes for removal of tape, cement or other adhesives)

Covered

Adult Diapers

Not Covered

Alcohol

Not Covered

Appliance Cleaners

Covered

Appliance Cover

Covered

Betadine

Not Covered

Cap, Stoma

Covered

Continent Device (e.g., plug, catheter)

Covered

Convex Insert

Covered

Cotton Balls

Not Covered

Deodorant

Covered

Drainage Bag or Bottle (bedside)

Covered

Drainage Tubing

Covered

Dressings (transparent or absorbent)

Covered

Filters

Covered

Gauze Pads (medicated or non-medicated)

Covered

Gloves

Not Covered

Irrigation Supplies and Set (e.g., bag, sleeve, clamp, catheters, catheter shields, cones, stoma plugs)

Covered

Lubricant

Covered

Moisturizers

Not Covered

Ostomy Accessory (convex insert)

Covered

Ostomy Belt

Covered

ITEM

COVERAGE

Ostomy Briefs

Covered

Ostomy Faceplate and Faceplate Set (e.g., convex oval, flat)

Covered

Ostomy Ring

Covered

Padding

Covered

Pouches (closed, drainable and urinary)

•

With or without barrier attached

Covered

•

For use with faceplate

Covered

•

For use on barrier with flange

Covered

Skin Barriers (e.g., liquid, powder, paste, ointments, wipes or swabs)

Covered

Skin Cleaners

Covered

Sterile Saline or Water Tape Underpads

Not Covered Covered Not Covered

SignatureValue™ Benefit Interpretation Policy SUBJECT:

OXYGEN

TITLE:

Hyperbaric Oxygen Therapy (HBO)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 1/5/01, 5/6/03, 9/17/03, 10/20/05, 6/5/06, 8/17/06, 7/16/08, 9/1/09, 9/2/10, 7/15/11, 8/16/11, 08/23/12, 08/22/13

Policy Number: O-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

See Medical Management Guidelines: Hyperbaric Oxygen Therapy and Topical Oxygen Therapy for coverage criteria (click Internal, Provider Portal or Member). 1.

HBO treatment when criteria are met.

D.

NOT COVERED 1. HBO treatment when criteria are not met.

E.

DEFINITIONS 1. Hyperbaric Oxygen Therapy (HBO): A type of treatment therapy in which the entire body is exposed to oxygen under increased atmospheric pressure.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

PAIN MANAGEMENT

TITLE:

Pain Management and Rehabilitation Program

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 9/17/03, 12/15/04, 8/17/06, 7/16/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: R-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Pain management for chronic and acute pain only when authorized and provided by a participating provider. Example includes, but is not limited to: a. Epidural injections when determined to be medically necessary

Refer to Medical Management Guidelines: Epidural and Facet Injections for Spinal Pain and MMG: Ablative Treatment for Spinal Pain (click Internal, Provider Portal or Member). D.

NOT COVERED 1. 2.

Pain rehabilitation programs unless mandated by State or Federal law and/or covered as Market Plan Enhancement (See Sections A and B) The following are not covered for pain management a. Acupuncture unless member has supplemental acupuncture benefit b. Acupressure unless member has supplemental acupressure benefit

c. d. e. f. g.

E.

DEFINITIONS 1.

F.

Biofeedback Family or vocational counseling Meals for outpatient program Massage therapy unless mandated by State or Federal law and/or covered as Market Plan Enhancements (See Sections A & B) Percutaneous Neuromodulation Therapy (PNT), also referred to as Percutaneous Electrical Nerve Stimulation (PENS), for the treatment of pain, as part of physical therapy or in the doctor’s office

Pain Rehabilitation Program: A program in a controlled environment that uses a coordinated, multi-disciplinary team to deliver, a concentrated program designed to modify pain behavior through the treatment of physiological, psychological, and social aspects of pain. The goal of the program is to give the member the tools to manage and control their pain and thereby improve their ability to function independently.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

PERVASIVE DEVELOPMENTAL DISORDER

TITLE:

Pervasive Developmental Disorder

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 02/01/13

Review Date: 6/20/02, 6/18/03, 10/20/05, 11/6/07, 12/16/08, 12/16/09, 2/16/11, 12/20/11, 12/27/12

Policy Number: P-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

This benefit interpretation policy applies to members with a diagnosed or suspected pervasive developmental disorder (PDD) or other related disorders of communication, language, and/or socialization. A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2. 3.

Assessment and coordination of care of the above listed disorders by the member's pediatrician or PCP (e.g., history, physical and management of medications) Referral for consultation and evaluation of individuals with suspected complex developmental and/or behavioral problems for confirmation of diagnosis. Treatment of any underlying coexistent medical condition (e.g., chromosomal abnormalities, congenital infection), based on medical necessity

Also see Attention Deficit Hyperactivity Disorder (ADHD), Developmental Delay, Mental Health: Inpatient, Mental Health: Outpatient, and Rehabilitation: Medical - Physical, Occupational and Speech Therapy policies D.

NOT COVERED 1.

Specific therapies for the treatment of suspected complex developmental and/or behavioral

2. 3.

4.

problems, including speech therapy. Individuals should be referred to appropriate community resources (e.g., school district, regional center) for these services. Assessment and therapy for learning disabilities (e.g., reading, mathematics and/or written expression disorders), except for underlying coexistent medical conditions Other non-medical therapies or treatment programs. Examples include, but are not limited to: a. Non-crisis mental health counseling b. Behavior modification program c. Vocational and community living skills d. Learning or reading disorders e. Psychoanalysis f. Biofeedback g. Residential living programs h. Non-crisis family counseling i. Learning consultants, non-licensed health professionals and licensed counselors j. Music integration therapy Prescription drugs, unless member has supplemental prescription benefit

Also see Attention Deficit Hyperactivity Disorder (ADHD), Developmental Delay, Mental Health: Inpatient, Mental Health: Outpatient, and Rehabilitation: Medical - Physical, Occupational and Speech Therapy policies E.

DEFINITIONS 1.

2.

F.

Learning Disability: A condition that exists when there is a meaningful difference between a child's current academic level of function and the level that would be expected for a child of that age and intelligence level. Pervasive Developmental Disorder (PDD): Pervasive developmental disorders are characterized by impaired development in social function, communication, and behavior. There is frequently impairment in social interaction, problems with verbal and nonverbal communication, and unusually or severely limited activities and interests. Examples of pervasive developmental disorders include autism, Rett's disorder, childhood disintegrative disorder, Asperger's disorder, and unspecified pervasive developmental disorder.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

PHYSICIAN SERVICES

TITLE:

Primary Care and Specialist Visits

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/2000

Review Date: 1/5/01, 5/6/03, 11/18/04, 8/17/06, 8/28/07, 9/25/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: P-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma HMO Licensure Rules, 310: 655-5-1: Comprehensive services shall include physician services, including consultant and referral services by a physician and other health professional services as necessary to provide allopathic, osteopathic, chiropractic, podiatric, optometric, and psychological services. If a service of a physician may also be provided under applicable State law by another type of health professional, an HMO may provide the service through these other health professionals.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

Physician/practitioner services (including network consultant and, where necessary, referral services by a physician) provided by a licensed physician/practitioner within the network (also see Emergency and Urgent Services policy) Examples of covered benefits include, but are not limited to: a. Diagnosis, therapy, surgery, and consultation rendered by a licensed provider within the member's contracted medical group b. Consultation by a second physician at the request of the member and/or attending provider, which includes a written report of the history and physical of the member

c. d. e.

f.

D.

NOT COVERED 1. 2. 3. 4. 5. 6.

E.

Treatment for any illness or injury provided by someone other than a licensed physician, surgeon, or healthcare professional Services that are oriented toward treating a social, developmental or learning problem as opposed to a medical problem Outpatient take home medications unless member has supplemental prescription drug benefit Employer requests for clearance to work or documentation as a reason for missed work Completion of forms, e.g., insurance, employment, school, sports, summer camp, Department of Motor Vehicle (DMV), etc. Services for: a. Inmates in a correctional institution b. Covered Persons that are engaged in active military duty c. Workers Compensation

DEFINITIONS 1.

2.

3. 4.

F.

Injectable drugs and medications administered in the physician's office as routine part of the medical office visit Preventive health examinations (see Periodic Health Examination/Preventive Services policy) Establishment and implementation of an appropriate treatment plan by the primary care physician in consultation with the specialist for members with complex or serious medical conditions, with an adequate number of access visits to specialists to accommodate the treatment plan Coumadin (anti-coagulation) monitoring performed at a free-standing clinic or a clinic within a hospital or that is attached to a hospital when referred and authorized by the member’s Primary Care Physician, Primary Medical Group, or IPA Note: A PCP office visit copayment may be assessed by the Doctor of Pharmacy (PharmD) at the Coumadin clinic when the PharmD is (1) licensed by the state and is performing within the scope of practice and (2) performing under the direct supervision of an M.D. or D.O. See Section E for the definition of “direct supervision”.

Direct supervision: The M.D. or D.O. does not have to be physically present in the room with the patient while services are provided, but must be present in the office suite to render assistance, if necessary. Physician: A doctor of medicine (M.D.), doctor of osteopathy (D.O.), doctor of dental surgery (D.D.S.) or dental medicine (D.M.), doctor of podiatric medicine (D.P.M.), doctor of chiropractic services (D.C.), or doctor of optometry (O.D.). Practitioner: A professional who provides health care services and is usually required to be licensed as defined by law (1998 NCQA definition). Provider: An institution or organization that provides services for the managed care organization's members. Examples of providers include hospitals and home health agencies (1998 NCQA definition).

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

PREVENTIVE HEALTH

TITLE:

Periodic Health Examination/Preventive Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 9/19/02, 12/5/02, 1/14/04, 5/4/06, 03/17/08, 5/22/08, 6/23/09, 9/2/10, 9/23/10, 2/16/11, 6/21/11, 06/28/12, 06/27/2013

Policy Number: P-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS FEDERAL: Throughout this document the following abbreviation are used • USPSTF means the United States Preventive Services Task Force. • PPACA means the federal Patient Protection and Affordable Care Act of 2010 Patient Protection and Affordable Care Act: UnitedHealthcare covers certain medical services under the Preventive Care Services benefit. Effective for plan years on or after September 23, 2010, of the federal Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered plans to cover certain “recommended preventive services” identified by PPACA under the Preventive Care Services benefit. For non-grandfathered plans, UnitedHealthcare will cover the recommended preventive services under the Preventive Care Services benefit as mandated by PPACA, with no cost sharing when provided by a Network provider. These services are described in the United States Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the CDC, and Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures periodicity guidelines. In addition to these mandated services, under the Preventive Care Services benefit, UnitedHealthcare also provides screening using CT colonography, prostate specific antigen (PSA), and screening mammography for adult women without age limits. Please visit http://www.ncsl.org/documents/health/ppaca-consolidated.pdf for legislation. 1.

Oklahoma Department of Insurance Title 36-6060.8: The prostate specific antigen (PSA) screening test is covered annually for the detection of prostate cancer for: a. Male members over the age of 40 who are at increased risk for prostate cancer, as determined by a physician

2.

3.

4.

B.

b. All male members over the age of 50 Oklahoma Department of Insurance Title 36-6060.8(a): Coverage for colorectal cancer examinations and laboratory test for cancer for any non-symptomatic covered individual, in accordance with standard, accepted published medical practicing guidelines for colorectal cancer screening, who is: 1. At least 50 years of age; or 2. Less than 50 years of age and at high risk for colorectal cancer according to the standard, accepted published medical practice guidelines. As used in this section, "health benefit plan" means any plan or arrangement as defined in subsection D of Section 6060.8 of Title 36 of the Oklahoma Statutes; provided, however, the provisions of this section shall not apply to policies or certificates issued to individuals or to groups with fifty (50) or fewer employees, or to plans offered under the state Medicaid program. Oklahoma Administrative Code 365:40-5-20 (10): Preventive health services, which shall be made available to enrollees and shall include at least the following: (A) Services for children from birth to age 21 as determined by the American Academy of Pediatrics in “Guidelines for Health Supervision”; (B) Immunizations for adults and children as recommended by the Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention, except those required for foreign travel and employment; (C) Periodic health evaluations for adults to include voluntary family planning services; and (D) Preventive services identified through HMO quality assurance program designed to contribute to achieving the US Department of Health and Human Services “Health People 2010” objectives. Oklahoma Department of Insurance Title 36: 6060.7 A. 1. Provide coverage for audiological services and hearing aids for children up to eighteen (18) years of age. 2. Such coverage: a. shall only apply to hearing aids that are prescribed, filled and dispensed by a licensed audiologist, and b. may limit the hearing aid benefit payable for each hearing-impaired ear to every fortyeight (48) months; provided, however, such coverage may provide for up to four additional ear molds per year for children up to two (2) years of age. B Nothing in this section shall be construed to extend the practice or privileges of any health care provider beyond that provided in the laws governing the provider’s practice and privileges C This requirement shall not apply to agreements, contracts or policies that provide coverage for a specified disease or other limited benefit coverage, or groups with fifty or fewer employees.

STATE MARKET PLAN ENHANCEMENTS Female members may self-refer to an OB/GYN contracting with their medical group one time annually for a pap smear, pelvic and breast exam.

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Notes: • Refer to state-specific mandated requirement for preventive health services. • If no state-mandated requirement, refer to the UnitedHealthcare Preventive Care Services Medical Management Guidelines (click Internal, Provider Portal or Member). 1.

2.

3.

Adult wellness examinations a. As referred by the member’s primary care physician/practitioner or medical group b. Examples include, but are not limited to: 1) Immunizations 2) Health education for the member 3) Screening mammograms, including physician interpretation 4) Clinical breast examination based on member’s risk factors 5) Screening pap smear for cervical cancer and pelvic examinations 6) Colorectal screening test/procedures for the early detection of colorectal cancer 7) Prostate cancer screening 8) Annual hearing examinations/screening to determine hearing loss 9) Annual vision examination to determine the need, if any, for vision correction 10) Educational materials as provided in a physician/provider's office 11) Smoking cessation informal counseling that is done as part of a preventive medicine Visit is a Covered Health Service and covered as part of the office visit. Well baby examinations (Note: Age varies depending on member’s plan, check member’s EOC.) a. Periodic health examinations and preventive health services as referred by the member’s primary care physician/practitioner or medical group b. Examples of preventive health services include, but are not limited to: 1) Eye and ear examinations 2) Head circumference measurements 3) Health education 4) Height and weight measurements 5) Immunizations 6) Laboratory tests 7) Physical examinations 8) Review of motor, language and social skills Well child examinations (Note: Age varies depending on member’s plan, check member’s EOC.) a. Periodic health examinations and preventive health services as referred by the member’s primary care physician/practitioner or medical group b. Examples of preventive health services include, but are not limited to: 1) Eye and ear examinations 2) Health education 3) Height and weight measurements 4) Immunizations 5) Laboratory tests (e.g., CBC, urinalysis) c. Physical examinations

Also see Educational Programs for Members, Hearing Screening, Hearing Examinations and Hearing Aids, Immunizations/Vaccinations and Vision Care and Services policies and UnitedHeatlhcare Preventive Health Services Medical Management Guidelines (click Internal, Provider Portal or Member). D.

NOT COVERED Adult Wellness/Well Baby/Well Child examinations a. Examples include, but are not limited to: 1) Health examinations and services requested by a third party (e.g., insurance, employment, school, sports, travel, pre-marital licensure and pre-adoption) 2) Completion of any third party related forms 3) Audiometric testing to determine a hearing aid prescription 4) Health examinations and services not meeting the criteria in Section C

E.

DEFINITIONS Periodic Health Examination: A health screening examination performed on a scheduled or routine basis based on the patient’s age, gender and health history or family history. Physician: A doctor of medicine (M.D.), doctor of osteopathy (D.O.), doctor of dental surgery (D.D.S.) or dental medicine (D.M.), doctor of podiatric medicine (D.P.M.), doctor of chiropractic services (D.C.), and doctor of optometry (O.D.). Practitioner: Professionals who provide health care services and are usually required to be licensed as defined by law Provider: An institution or organization that provides services for the managed care organization's members. Examples of providers include hospitals and home health agencies Well Baby Care: Preventive health services for infants and children under 2 years of age performed in a physician’s office, including immunizations. (Note: Age varies depending on member’s plan, check member’s EOC.) Well Child/Adolescent Care: Preventive health services performed in a physician’s office, including immunizations, for children between the ages of 2 and 17. (Note: Age varies depending on member’s plan, check member’s EOC.) Well Adult Care: Care for both male and female members aged 18 and over.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

RADIOLOGY

TITLE:

Diagnostic and Therapeutic Radiology Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 12/6/01, 12/5/02, 5/6/03, 9/17/03, 6/23/04, 3/24/05, 8/17/06, 10/11/06, 5/22/08, 9/25/08, 12/16/08, 9/1/09, 9/2/10, 06/21/11, 8/16/11, 08/23/12, 08/22/13

Policy Number: R-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Diagnostic and therapeutic radiological services (inpatient or outpatient) used for screening, detection or treatment of disease, when such services are determined to be medically necessary. Examples include, but are not limited to: a. Standard X-rays (See Section E for definition) 1) Bone density studies when medical criteria are met 2) Plain film X-rays 3) Mammograms, including digital mammograms [Refer to Medical Management Guidelines: Breast Imaging (click Internal, Provider Portal or Member)] 4) Intravenous Pyelogram (IVP) 5) Kidney, Ureter and Bladder (KUB) X-ray 6) Obstetrical ultrasound 7) Oral and rectal contrast gastrointestinal studies (such as upper GIs, barium enemas, and oral cholecystograms)

b.

Specialized Scanning, Imaging and Other Specialized Procedures (See Section E for definition) 1) Ultrasonography (except obstetrical ultrasound or bone density ultrasound; see Standard X-rays above) 2) Computed Tomography (CT scan) 3) Single photon emission computed tomography (SPECT) 4) Magnetic Resonance Imaging (MRI) Refer to Medical Management Guidelines: Breast Imaging (click Internal, Provider Portal or Member) 5) Magnetic Resonance Angiogram (MRA) 6) Nuclear scans 7) Invasive radiological procedures such as myelogram, cystogram, angiogram (includes heart catheterization), arthrogram 8) Positron Emission Tomography (PET) scans when medical criteria are met. 9) Other specialized procedures: EKG, EEG, EMG Also see Periodic Health Examinations/Preventive Services policy D.

NOT COVERED 1.

E.

DEFINITIONS 1.

2.

F.

Non-medically indicated or unnecessary radiological services (diagnostic and/or therapeutic) which include, but are not limited to: a. Experimental or unproven tests not medically indicated b. Radiology studies requested by an employer or school c. Thermography d. Radiological tests and procedures in preparation for or during a non-covered service

Specialized Scanning, Imaging and Other Specialized Procedures: Defined to include those which, unless specifically classified as standard X-rays, are digitally processed, or computergenerated, or which require contrast administered by injection or infusion. Examples include, but are not limited to, the following scanning and imaging procedures: CT, PET, SPECT, MRI, MRA, EKG, EEG, EMG and nuclear scans, angiograms (includes heart catheterization), arthrograms, myelograms, and ultrasounds, not including obstetrical ultrasounds or bone density ultrasounds. Standard X-Rays: Defined to include conventional plain film X-rays, oral and rectal contrast gastrointestinal studies (such as upper GIs, barium enemas, and oral cholecystograms), mammograms, obstetrical ultrasounds, and bone mineral density studies (including ultrasound for bone density and DEXA scans).

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

REHABILITATION

TITLE:

Cardiac Rehabilitation Services - Outpatient

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 9/3/99

Effective Date: 1/1/00

Review Date: 7/7/00, 12/5/02, 12/18/03, 6/23/04, 5/4/06, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: R-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS None

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Outpatient cardiac rehabilitation services when medical criteria are met. D.

NOT COVERED Cardiac rehabilitation services that do not meet medical criteria

E.

DEFINITIONS Cardiac Rehabilitation Program: Comprehensive, long-term services involving medical evaluation, prescribed exercise and monitoring, cardiac risk factor modification, education and counseling.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

REHABILITATION

TITLE:

Chemical Dependency/Substance Abuse Rehabilitation

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 1/1/00

Review Date: 12/5/02, 12/18/03, 2/16/06, 2/14/08, 4/15/09, 4/21/10, 4/19/11, 04/26/12, 04/25/13

Policy Number: R-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

Some members may have additional chemical dependency/substance abuse rehabilitation benefit. For member-specific coverage and limitations for chemical dependency/substance abuse rehabilitation benefit, refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the Member Services Department.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

None unless mandated by State or Federal law and/or covered as Market Plan Enhancements (See Sections A & B)

Also see Detoxification: Chemical Dependency/Substance Abuse policy D.

NOT COVERED

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

REHABILITATION

TITLE:

Cognitive Rehabilitation Therapy

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 12/5/05

Effective Date: 02/01/13

Review Date: 6/11/07, 12/16/08, 12/16/09, 6/22/10, 2/15/11, 12/20/11, 12/27/13

Policy Number: R-008

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

Outpatient cognitive rehabilitation therapy is covered only for the following: a. Initial neuropsychological testing to identify functional deficits and establish a treatment plan (Also see Neuropsychological Testing policy) b. Medically necessary treatment of functional deficits from a traumatic brain injury (TBI) or cerebral vascular insult as documented by the neuropsychological testing The cognitive rehabilitation therapy includes a variety of therapy methods (OT, PT, ST, psychology) that retrain or alleviate problems caused by TBI or cerebral vascular insult, e.g. deficits of visual processing, language, reasoning and problem solving. The cognitive rehabilitation treatment plan must include: • Tasks that are designed to reinforce or re-establish previously learned patterns or to establish compensatory mechanisms for documented functional deficits • Therapy activities that are systematic, structured, goal directed and individualized to treat the patient’s documented functional deficits; • The member must be able to actively participate in the authorized treatment plan and significant cognitive improvement is expected.

3.

Inpatient cognitive rehabilitation therapy is covered only when a member also meets criteria for inpatient medical rehabilitation services. See Medical Rehabilitation (Physical, Occupational and Speech Therapy) policy.

Notes: • Outpatient Cognitive Rehabilitation is subject to the applicable Outpatient Rehabilitation Therapy copayment and benefit limitations, if any. Check the individual member’s EOC/SOB. •

D.

Cognitive rehabilitation therapy can be performed by participating/contracting licensed providers within the scope of their licensure, e.g. occupational, physical and speech therapists/pathologist, psychologist, or a physician

NOT COVERED 1.

Cognitive rehabilitation therapy for any condition other than traumatic brain injury (TBI) or cerebral vascular insult 2. Cognitive rehabilitative therapy for a member who: a. Is in a vegetative or custodial state; b. Has met the goals of the treatment plan; or c. Cannot progress to meet the treatment plan goals 3. Cognitive behavioral therapy also known at cognitive therapy (See Section E for Definition) 4. In-home cognitive rehabilitation therapy unless documented to be medically necessary and is prior authorized by the member’s Primary Medical Group or UnitedHealthcare Note: In-home cognitive rehabilitation is considered home health and is subject to the applicable home health visit co-payment/coinsurance, deductibles and benefit limitations, if any. Check the individual member’s EOC/SOB.) 5. Assisted living facilities or residential living settings (not licensed as a Skilled Nursing Facility). 6. Community integration programs (services do not require the skills of a healthcare professional) See Skilled Nursing Facility Policy for skilled services covered E.

DEFINITIONS 1.

2.

F.

Cognitive Rehabilitation Therapy: Therapy for the treatment of functional deficits as a result of traumatic brain injury or cerebral vascular insult. It is intended to help in achieving the return to a higher level of cognitive ability. This therapy is direct (one-on-one) patient contact. Cognitive Behavioral Therapy (also known as Cognitive Therapy): Psychotherapy where the emphasis is on the role of thought patterns in moods and behaviors.

REFERENCES 1. 2. 3.

National Institutes of Health, Rehabilitation of Persons with Traumatic Brain Injury Consensus Statement (October 26-28, 1998) National Academy of Neuropsychology Cognitive Rehabilitation (May 2002) Blue Cross/Blue Shield Executive Summary Cognitive Rehabilitation for Traumatic Brain Injury in Adults (December 2002) http://www.bcbs.com/tec/vol17/17_20.html

SignatureValue™ Benefit Interpretation Policy SUBJECT:

REHABILITATION

TITLE:

Medical Rehabilitation (Physical, Occupational and Speech Therapy)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 9/19/02, 12/5/02, 5/6/03, 9/17/03, 1/14/04, 2/2/05, 10/20/05, 8/17/06, 2/6/07, 6/11/07, 11/6/07, 7/16/08, 09/02/08, 10/21/09, 6/22/10, 12/20/11, 10/25/12

Policy Number: T-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

2.

3.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Department of Insurance 365:40-5-30 (4): Short-term inpatient rehabilitation services are covered when member is expected to have significant improvement in condition within two (2) months. Oklahoma Administrative Code 365:40-5-20 (10): Inpatient and outpatient care for treatment of the birth defect known as cleft lip or cleft palate or both including medially necessary oral surgery, orthodontics and otologic, audiological, and speed/language treatment. OS 887.17 (Effective date 04/11/08) A. 1. Any person licensed under this act as a physical therapist or physical therapist assistant shall treat human ailments by physical therapy only under the referral of a person licensed as a physician or surgeon with unlimited license, or the physician assistant of the person so licensed, and Doctors of Dentistry, Chiropractic and Podiatry, with those referrals being limited to their respective areas of training and practice; provided, however, a physical therapist may provide services within the scope of physical therapy practice without a physician referral to children who receive physical therapy services pursuant to the Individuals with Disabilities Education Improvement Act of 2004, as may be amended, and the Rehabilitation Act of 1973, Section 504, as may be amended. Provided further, a plan of care developed by a person authorized to provide services within the scope of the Physical Therapy Practice Act shall be deemed to be a prescription for purposes of providing services pursuant to the provisions of the Individuals with Disabilities Education Improvement Act of 2004, as may be amended, and Section 504 of the Rehabilitation Act of 1973, as may be amended.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to

Sections A and B for additional covered benefits not listed in this Section.

Note:  For member specific coverage and limitations for physical, occupational and speech therapy or rehabilitation services, refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the Customer Service Department.  Voice therapy is subject to any benefit limitations and/or exclusions applicable to speech therapy.  See Section A for physical therapy referrals. 1.

2.

Physical, occupational and speech therapy services must meet all of the following criteria: a. Therapy services must be such that only a qualified therapist or a person supervised by a qualified therapist can safely perform the services. b. Therapy services must be provided with the expectation that the member’s condition will improve or that the service is necessary to establish a safe and effective maintenance program. 1) Physical limitations and goals must be documented and progress recorded. c. Amount, frequency and duration of the therapy services must be reasonable. d. Services must relate directly and specifically to a written treatment plan established by a physician after consulting with the qualified therapist (physical and/or occupational) and/or speech pathologist or audiologist. Therapy services are covered in the following settings: a. Acute Inpatient Rehabilitation: Inpatient acute rehabilitation provides an intense multidisciplinary service to restore or enhance function, post injury or illness. Inpatient acute rehabilitation is medically necessary when ALL of the following criteria are met: 1. The patient requires treatment from a multidisciplinary team consisting of at least two therapies (e.g., physical therapy, occupational therapy, speech therapy). 2. The patient is stable enough medically and is capable and willing to participate in intensive therapy for a minimum of three hours per day, at least five days per week. 3. The rehabilitation program is expected to result in significant therapeutic improvement over a clearly defined period of time. 4. The rehabilitation program is individualized, and documentation outlines quantifiable, attainable treatment goals. 5. Rehabilitation is required in an inpatient rehabilitation facility rather than a less intense setting. Rehabilitative care services are determined by the patient’s functional needs, and the availability of resources. Documentation provided in the patient’s medical record must support medical necessity and should include relevant medical history, including the patient’s rehabilitation potential and prior level of function, physical examination, and results of pertinent diagnostic test or procedures. In addition, the documentation must reflect the ongoing assessment and necessary adjustments to the plan of care. Current functional status and measurable goals individualized to the needs and abilities of the patient should be part of the plan of care. The patient’s progress toward established goals should be reviewed at least weekly and should include objective measurements (e.g., FIM scores) as well as a clinical narrative which demonstrates functional improvement and progress towards attainable treatment goals as a result of the therapy provided.

b.

Inpatient Skilled Nursing Facility (SNF) 1) Skilled nursing facility care coverage is provided if all of the following three factors are met: a) The member requires skilled nursing services or skilled rehabilitation services b) These skilled services are required on a daily basis

Note: Daily basis for the purpose of SNF care is defined as Skilled Nursing and or Skilled Rehabilitative Therapy services given at a minimum 5 days a week for 2.5 – 3 hours per day. c) The daily skilled services can be provided only on an inpatient basis in a SNF Note: If any one of these three factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. 2) Basic requirements that also need to be met include: a) Services must be provided under physician orders, must require the skills of qualified or professional health personnel such as RNs, LVN/LPNs, and/or therapists (physical, occupational, speech pathologists or audiologists) and must be provided directly by or under the supervision of these skilled nursing or rehabilitation personnel who can safely perform the services. b) Services must be provided with the expectation that the member’s condition will improve or that the service is necessary to establish a safe and effective maintenance program. c) The amount, frequency and duration of the services must be reasonable. 3) Examples include, but are not limited to: a) Nursing care, provided by or under the supervision of a RN, examples include (1) IV medications and fluids (2) Enteral feedings (3) Suction and tracheostomy care (4) Surgical wound care and dressing changes b) Bed and board in connection with the furnishing of nursing care c) Physical, occupational and/or speech therapy furnished by the facility or by others under arrangement with the facility d) Medical social services e) Drugs, biologicals, supplies, appliances, and equipment for use in the facility and which are ordinarily furnished by the facility for the care and treatment of the inpatient member f) Monitoring and treatment of clinically complex situations requiring any one of the following: (1) At least one physician visit and 4 physician order changes in 14 days (2) At least 2 physician visits and 2 physician order change in 14 days (3) Examples include:  Internal bleeding  Transfusions  DVT or PE  Insulin-dependent diabetic with frequent order changes  Dialysis Note: Also see Skilled Nursing Facility (SNF) Care policy.

c.

3.

Outpatient 1) Physician’s office only when done by a licensed therapist and performed in a participating/contracting physician’s office 2) Therapist’s office 3) Member’s place of residence Examples of covered Medical Rehabilitation Services: a. Speech therapy is limited to medically necessary therapy to treat speech disorders caused by a defined illness, disease, injury, congenital anatomic anomaly, or surgery (e.g., cleft palate repair, macroglossia, velo-pharyngeal incompetence). Examples include but are not limited to: Speech therapy for children with speech delay or delayed hearing as a result of bilateral chronic otitis media when documented by a PCP, Pediatrician or ENT specialist that the medical condition resulted in speech delay or delayed hearing, up to the point when the child attains the expected functional speech level for his/her age or when no further progress is documented (plateau) b. Physical and occupational therapies include, but are not limited to: 1) Ultrasound, shortwave, and microwave diathermy treatments 2) Range of motion tests 3) Gait training 4) Therapeutic exercises 5) Aqua/pool therapy, only as part of an authorized treatment plan conducted by a licensed physical therapist with the therapist in attendance 6) Fluidized therapy (fluidotherapy) as a part of an authorized physical therapy treatment plan for the treatment of acute or subacute, traumatic or nontraumatic, musculoskeletal disorders of the extremities c. Circumstances under which therapy services are covered include, but are not limited to: 1) A terminally ill member who begins to exhibit self care, mobility and/or safety dependence 2) A member who has an unhealed, unstable fracture of the leg which requires regular exercise until the fracture heals in order to maintain function of the leg 3) A member who requires physical, occupational, and/or speech therapy for brain injury, when deemed medically necessary by UnitedHealthcare’s medical director. Please see Cognitive Rehabilitation Policy.

Note:  There must be a documented need to continue therapy and an estimate of how long the services may be needed. The physician must review the plan of treatment and the clinical records every 30 days. The member’s limits and goals of therapy must be included in the documentation. Also see Medical Management Guideline: Breast Reconstruction Post Mastectomy (click Internal, Provider Portal or Member). D.

NOT COVERED 1. 2.

Therapy when member has either attained therapy treatment plan goals or is unable to attain the treatment plan goals General exercises that promote overall fitness and flexibility

3. 4. 5. 6. 7. 8. 9.

10.

11. 12. 13. 14. 15.

Activities that provide a diversion or general motivation Massage therapy unless mandated by State or Federal law and/or Market Plan Enhancements (Refer to Sections A and B) Recreational therapy Maintenance therapy Long term therapy/rehabilitation for chronic conditions Speech therapy for functional articulation disorders such as stuttering, lisping, or delayed speech Oral sensorimotor therapy or myofunctional therapy is not covered for the treatment of tongue thrust, deviant or reverse swallow, or oral myofunctional disorders in children who do not have a diagnosed neuromuscular disease adversely affecting swallowing. Services that are primarily oriented towards treating a social, developmental or learning problem rather than a medical problem, including, but not limited to the following: a. Autism b. Attention deficit hyperactivity disorder c. Dyslexia Vocational and prevocational assessment and training related solely to specific employment opportunities, work skills or work settings Percutaneous Neuromodulation Therapy (PNT), also referred to as Percutaneous Electrical Nerve Stimulation (PENS), for the treatment of pain , as part of physical therapy or in the doctor’s office Sensory Integration Therapy Coordination Therapy Inpatient rehabilitation solely for the purpose of providing cognitive rehabilitation therapy when treatment of the member’s medical condition does not otherwise meet criteria for inpatient intensive skilled rehabilitation nursing care, physical therapy, occupational therapy, or speech therapy services

Also see Developmental Delay, Cognitive Rehabilitation, Pervasive Developmental Disorder, and Attention Deficit Hyperactivity Disorder (ADHD) policies E.

DEFINITIONS 1.

2.

3.

Acute Rehabilitation Program: A relatively intense rehabilitation program necessitating a multidisciplinary coordinated team approach to upgrade the member’s ability to function as independently as possible. A program of this scope usually includes intensive skilled rehabilitation nursing care, physical therapy, occupational therapy, and, if needed, speech therapy. Fluidized therapy (Fluidotherapy): High intensity heat modality consisting of a dry whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid. Maintenance Therapy: Therapy with the goal to maintain the functional status or to prevent decline in function

4.

5.

Multidisciplinary Team Approach: Usually includes a physician specializing in rehabilitation, rehabilitation nurse, social worker and/or psychologist, and those therapies (physical, occupational, and/or speech) involved in the member’s care. At a minimum, a team must include a physician, rehabilitation nurse and one therapist. Occupational Therapy: Non-surgical treatment necessary for the identification and alleviation of mental and/or physical conditions that limit an individual's ability to perform the activities of daily living. Treatment focuses on increasing independence and minimizing reoccurrence through

6.

7.

8. 9. 10.

11. F.

education and the use of therapeutic exercise and physical activity at home or at work. Physical Therapy: Non-surgical treatment necessary for the identification, restoration, and improvement of functions that have been impaired by illness, disease, surgery, trauma or injury. Treatment includes, but is not limited to, therapeutic exercise, physical activity, and training in the activities of daily living. Place of Residence: Wherever the member makes their home. This may be their own dwelling, an apartment, a relative’s home, home for the aged, or some other type of institution other than an acute hospital or licensed skilled nursing facility. Qualified Physical or Occupational Therapist: A licensed physical or occupational therapist in the state where he/she is practicing. Speech Pathologist Services: Services necessary for the diagnosis and treatment of (1) speech and language disorders that cause communication problems, or (2) swallowing disorders (dysphagia). Speech Therapy Services: Services necessary for the diagnosis and treatment of speech and language disorders which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communications disability. Therapy Services: Includes physical, occupational and speech therapy.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

REHABILITATION

TITLE:

Pulmonary Rehabilitation - Outpatient

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 12/5/02, 3/24/05, 5/4/06, 5/21/08, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: R-006

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS For Federal employees, please check the FEHB brochure for covered benefits.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

Pulmonary rehabilitation programs are covered only when determined to be medically necessary by a UnitedHealthcare Medical Director or designee. Patient Selection Criteria a. Inpatient pulmonary rehabilitation for severe COPD when a member can not be managed in an outpatient setting. 1) Member has failed in outpatient setting due to anxiety attacks resulting in breathlessness requiring emergency treatment and admission to the inpatient setting. 2) Member is requiring an integrated program for pre-op or post-op, post intensive care in disabling respiratory disease and must be assessed for mechanical support and oxygen (long-term) needs. b. Outpatient pulmonary rehabilitation is for members with moderate to severe COPD (FEV1 < 60% of predicted). These members must be stable medically and have disabling symptoms while on optimal medical management. c. Home based for members with moderate to severe COPD (FEV1 < 60% of predicted) who have disabling symptoms while on optimal medical management. 1) Used to evaluate the member in the home at submaximal activities, to maximize the patient’s potential for activities of daily living. 2) Members must rate their strength and breathlessness during the activities in the home on a Borg scale, which they are taught. Note: For home based programs administered by trained professionals, Members should meet the definition of Homebound. See the Home Health Care and Home Visits policy for Homebound definition. d. Member must have stopped smoking for 6 months or longer.

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

None unless covered under Section B. D.

NOT COVERED Pulmonary rehabilitation program is not a covered benefit unless covered under Section B.

E.

DEFINITIONS Pulmonary Rehabilitation Program: A program for persons with chronic lung disease, which includes medical management, education, emotional support, exercise, breathing retraining and nutritional counseling.

F.

REFERENCES Outpatient Physical Therapy and Comprehensive Outpatient Rehabilitation Facility Services Manual, OUT, § 403.5

SignatureValue™ Benefit Interpretation Policy SUBJECT:

RESPITE CARE

TITLE:

Respite Care

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 12/5/02, 1/14/04, 5/4/06, 5/22/08, 6/23/09, 6/22/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: R-007

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS None

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Respite care is covered only if the member has signed a Hospice Election Statement (see Hospice Care and Services policy). D.

NOT COVERED All care and services not directly related to Hospice

E.

DEFINITIONS Respite Care: Short-term inpatient care provided to the member only when necessary to relieve the family members or other persons for caring for the member at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SECOND AND THIRD OPINION

TITLE:

Member Initiated Second and Third Opinion

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 02/01/13

Review Date: 12/5/02, 1/14/04, 2/16/06, 12/7/06, 12/16/08, 4/15/09, 2/17/10, 2/16/11, 12/20/11, 12/27/12

Policy Number: S-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

3.

A second opinion/evaluation will be covered if the opinion is provided at the member’s request to determine the advisability of having an elective surgery or a major non-surgical diagnostic or therapeutic procedure. A second opinion may include, but is not limited to: a. A history and physical examination of the member b. Any covered diagnostic testing required to evaluate the need for surgery or procedure. Diagnostics must be obtained in network when possible. If the first two opinions differ, a third opinion will be covered if member meets above criteria (C.1).

Notes: • All second and third opinions, whenever possible, should be provided in-network and must be authorized by the member’s medical group/IPA or UnitedHealthcare. Out-of-network

second/third opinion will be considered if there is no available or appropriate in-network provider and must be authorized by the member's medical group/IPA or UnitedHealthcare. This requirement does not apply when state mandate requires another process. Refer to Section A. •

D.

Once the second or third opinion is provided, regardless of where it was rendered, all diagnostic testing, treatment and/or surgical intervention must be authorized and directed by the member's contracting provider.

NOT COVERED 1. 2.

Self-referred second opinion Second opinion for a non-covered service

E.

DEFINITIONS

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SERVICES WHILE CONFINED/INCARCERATED

TITLE:

Services While Confined/Incarcerated

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 12/18/03

Effective Date: 1/1/04

Review Date: 2/16/06, 2/14/08, 8/07/08, 8/14/08, 4/15/09, 4/21/10, 4/19/11, 04/26/12, 04/25/13

Policy Number: S-008

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/MARKET MANDATED REGULATIONS 1.

Oklahoma Statutes §6060.4a of Title 36 (effective 01/01/2009) SECTION 1. NEW LAW A new section of law to be codified in the Oklahoma Statutes as Section 6060.4a of Title 36, unless there is created a duplication in numbering, reads as follows: No health benefit plan, including, but not limited to, the State and Education Employees Group Health Insurance Plan, that is offered, issued or renewed in the state on or after January 1, 2009, shall exclude otherwise allowable claims which occur in conjunction with the arrest or pretrial detention of the policyholder prior to adjudication of guilt and sentencing to incarceration of such policyholder. The reimbursement rate for out-of-network claims for these services shall be set at the current Medicare rate. SECTION 1. This act shall become effective November 1, 2008.

B.

MARKET PLAN ENHANCEMENTS 1.

C.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Services received while imprisoned or incarcerated unless required by state or federal law (See Section A) (see Section E.1. for definition of “services while imprisoned or incarcerated”)

2.

Emergency services or urgently needed services (see Emergency and Urgent Services policy)

Note: In these situations, Member usually has to pay out-of-pocket and must be reimbursed by UnitedHealthcare or designee D.

NOT COVERED 1.

E.

DEFINITIONS 1.

F.

Services while imprisoned or incarcerated except as stated in Section C

Services While Imprisoned or Incarcerated: Services required for injuries or illnesses experienced while imprisoned or incarcerated pursuant to federal, state or local law are not covered unless required by federal or state law. UnitedHealthcare will reimburse Members their out-of-pocket expenses for services received while imprisoned or incarcerated, if the services are Covered Services under the terms of this Health Plan UnitedHealthcare 's liability with respect to out-of-network expenses for Covered Services provided in a state or county hospital is limited to the current Medicare rate pursuant to state law.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SEXUAL DYSFUNCTION

TITLE:

Erectile Dysfunction (Impotence)

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 02/01/13

Review Date: 9/19/02, 6/18/03, 3/24/05, 12/7/06, 12/16/08, 12/16/09, 2/16/11, 12/20/11, 12/27/12

Policy Number: S-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1. 2.

C.

None

Members may have supplemental outpatient drug benefit for drugs for sexual dysfunction. Refer to the member’s EOC/SOB to determined coverage eligibility. The following benefits are covered only for members whose group contracts have been issued, amended or renewed prior to January 1, 2005: a. Diagnostic services 1. A single dose of alprostadil urethral suppository (MUSE), only when administered under direct physician supervision as part of a diagnostic evaluation b. Treatment of organic or psychogenic erectile dysfunction 1. Surgical treatment, including but not limited to: 1) Outpatient psychotherapeutic treatment (see Mental Health: Outpatient policy) 2) External vacuum devices, pumps, or constriction rings (e.g., ErecAid) 2. Surgical treatment, including but not limited to: 1) Implantation of rigid, semi-rigid, or inflatable penile prosthesis (e.g., Flexirod) 2) Penile revascularization surgery

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

For state-specific coverage information that applies to group contracts issued, amended or renewed prior to January 1, 2005, see Section B.

1.

2. D.

Diagnostic services, including but not limited to: a. Medical history review b. Physical examination c. Routine laboratory services, including measurement of the following: 1) Serum testosterone 2) Gonadotropin levels 3) Serum prolactin 4) Thyroxin d. Nocturnal penile tumescence testing e. Psychiatric evaluation when appropriate (see Mental Health: Outpatient policy) Testosterone injections for documented low testosterone levels

NOT COVERED For state-specific coverage information that applies to group contracts issued, amended or renewed prior to January 1, 2005, see Section B. 1.

E.

DEFINITIONS 1.

F.

Sexual dysfunction or inadequacy medications/drugs, procedures, services, and supplies, including but not limited to: a. Psychotherapeutic treatment, unless member has supplemental benefit b. External vacuum devices, pumps or constriction rings (e.g., ErecAid) c. Surgical procedures, including penile revascularization and implantation of penile prosthesis (e.g., FlexiRod) d. Prescription or injectable medications, including but not limited to: 1) Alprostadil urethral suppository (MUSE) 2) Viagra 3) Testosterone patches 4) Caverject 5) Papaverine 6) Regitine

Erectile Dysfunction: Erectile dysfunction (impotence) refers to a man's inability to achieve or maintain an erection that is sufficient to have satisfactory sex. There are two general causes of erection problems: physical (related to the blood vessels and/or nerves) and psychological. Most erection problems are due to a combination of blood vessel, nerve, and psychological factors.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SKILLED NURSING FACILITY (SNF)

TITLE:

Skilled Nursing Facility (SNF) Care

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 1/1/00

Review Date: 9/17/03, 7/21/05, 8/28/07, 11/6/07, 12/16/08, 2/17/10, 2/16/11, 6/21/11, 02/23/12

Policy Number: S-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

None

STATE MARKET PLAN ENHANCEMENTS 1.

None

Notes:  Days spent out of a SNF when a member is transferred to an acute hospital setting are not counted toward the SNF day limits when the member is transferred back to a SNF. 

C.

In order to receive SNF benefit coverage, the member must either be out of the SNF for 60 consecutive days, or if the member remains in a SNF, then the member must not have received skilled nursing services or skilled rehabilitation care for 60 consecutive days.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Refer to the member's SOB for specific number of SNF days covered. Benefits shall not exceed the limits set forth in the Schedule of Benefits. 1.

2.

Inpatient skilled care/services that are provided in a UnitedHealthcare contracted skilled nursing facility (SNF). Services include room and board, skilled nursing care, and other customarily provided services. Skilled nursing care coverage is provided if all of the following three factors are met:

a. b.

3.

4.

The member requires skilled nursing services or skilled rehabilitation services These skilled services are required on a daily basis Note: Daily basis for the purpose of SNF care is defined as Skilled Nursing and/or Skilled Rehabilitative Therapy services given at a minimum 5 days a week for 2.5 – 3 hours per day. c. The daily skilled services can be provided only on an inpatient basis in a SNF Note: If any one of these three factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. Basic requirements that also need to be met include: a. Services must be provided under physician orders, must require the skills of qualified or professional health personnel such as RNs, LVN/LPNs, and/or therapists (physical, occupational, speech pathologists or audiologists) and must be provided directly by or under the supervision of these skilled nursing or rehabilitation personnel who can safely perform the services. b. Services must be provided with the expectation that the member’s condition will improve or that the service is necessary to establish a safe and effective maintenance program. c. The amount, frequency and duration of the services must be reasonable. Examples include, but are not limited to: a. Nursing care, provided by or under the supervision of a RN, examples include 1) IV medications and fluids 2) Enteral feedings 3) Suction and tracheostomy care 4) Surgical wound care and dressing changes b. Bed and board in connection with the furnishing of nursing care c. Physical, occupational and/or speech therapy furnished by the facility or by others under arrangement with the facility d. Medical social services e. Drugs, biologicals, supplies, appliances, and equipment for use in the facility and which are ordinarily furnished by the facility for the care and treatment of the inpatient member f. Monitoring and treatment of clinically complex situations requiring any one of the following: 1) At least one physician visit and 4 physician order changes in 14 days 2) At least 2 physician visits and 2 physician order change in 14 days 3) Examples include:  Internal bleeding  Transfusions  DVT or PE  Insulin-dependent diabetic with frequent order changes  Dialysis

Note: Inpatient services rendered in a Transitional Care Unit (TCU) of an acute care hospital are classified as subacute care, if the TCU is licensed as a separate and distinct Medicare-certified facility. Inpatient days spent in a TCU count towards the SNF benefit limit per benefit period. D.

NOT COVERED 1. 2.

Custodial care Respite services

3. 4. 5. E.

DEFINITIONS 1.

2.

3.

4.

F.

Services of a private duty nurse unless covered under Section A. Services of a private duty attendant Outpatient drugs and medications unless the member has a supplemental prescription benefit

Custodial Care: Services that assist a member in their normal activities of daily living such as bathing, eating, getting in and out of bed, etc. This includes the administration of a simple diet or routine oral medication. Private Duty Nursing Services: Private duty nursing services encompass nursing services for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility. Skilled Services and/or Skilled Rehabilitation Services: Services that are rendered under physician orders, require the skills of qualified technical or professional health personnel such as RNs, LVN/LPNs, and/or therapists (physical, occupational, speech pathologists or audiologists), and must be provided directly by or under the supervision of these skilled nursing or skilled rehabilitation personnel. Transitional Care- (Also called subacute care or post-acute care.) Type of short-term care provided by a Skilled Nursing Facility to a member which may include rehabilitation services, specialized care for certain conditions (such as stroke and diabetes) and/or post-surgical care and other services associated with the transition between the hospital and home. Residents on these units often have been hospitalized recently and typically have more complicated medical needs. The goal of subacute care is to discharge residents to their homes or to a lower level of care.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SLEEP APNEA

TITLE:

Sleep Apnea

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 02/01/13

Review Date: 5/12/00, 3/1/01, 3/21/02, 5/6/03, 6/23/04, 5/19/05, 9/13/06, 05/10/07, 06/25/08, 12/16/08, 12/16/09, 2/16/11, 12/20/11, 12/27/12

Policy Number: S-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Services necessary for the diagnosis and treatment of sleep apnea when medical criteria are met. • For surgical management of sleep apnea, refer to the Medical Management Guidelines: Non-Surgical Treatment of Sleep Apnea and MMG: Surgical Treatment of Sleep Apnea (click Internal, Provider Portal or Member). • Also see the Medical Management Guidelines: Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders (click Internal, Provider Portal or Member)

Also see DME, Prosthetics, Corrective Appliances and Medical Supplies Grid D.

NOT COVERED 1. 2.

Sleep therapy (hypnosis) Surgeries or treatments that are dental in nature

3. 4. 5.

E.

DEFINITIONS 1. 2.

F.

Prescription drugs, unless member has supplemental prescription benefit Laser assisted uvulopalatopharyngoplasty (LAUP) Mandibular devices for treatment of sleep apnea for members with any of the following: a. Overt temporomandibular joint (TMJ) restriction b. Painful or loud TMJ noises c. Local sites of severe joint or muscle tenderness Note: For coverage information for mandibular devices for the treatment of sleep apnea, see the DME, Prosthetics, Corrective Appliances and Medical Supplies Grid and the MMG: NonSurgical Treatment of Sleep Apnea (click Internal, Provider Portal or Member.

Apnea: Cessation of airflow for at least 10 seconds. Mandibular Devices: Devices that modify mandibular position and keep the pharyngeal airspace open by forward positioning of the mandible by several millimeters, which also brings the tongue forward. These devices, also known as mandibular advancement devices (MADs), are attached to one or both dental arches to advance the mandible 50% to 100% of the maximum protrusive movement. In addition to holding the mandible and tongue in an optimal position, they modify hyoid bone position and the lower airway space below the tongue.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SPECIALIZED FOOTWEAR

TITLE:

Shoes and Foot Orthotics

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 12/05/02, 09/17/03, 10/6/04, 2/16/06, 2/14/08, 4/15/09, 4/21/10, 4/19/11, 04/26/12, 04/25/13

Policy Number: S-003

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

2.

C.

Oklahoma Statutes §36-6060.2: Podiatric appliances for prevention of complications associated with diabetes are covered.

Some members may have additional footwear benefits. Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the Member Services Department to determine eligibility If not listed as an exclusion or limitation in the Schedule of Benefits, custom made foot orthotics are a covered benefit for members who meet any of the following criteria: a. Leg length discrepancy/disfigurement as a result of polio, congenital abnormality or hip replacement b. For the treatment of fractured foot bones when medically necessary c. For post-operative use after foot surgery when medically necessary d. For bone spurs, bunions, or other foot problems in lieu of surgery

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. 2.

Prosthetic shoe when used as a structural device to replace all of a foot or when a large portion of the member's forefoot (front part) is missing Orthopedic shoe if part of a leg brace

3.

Therapeutic shoe and shoe inserts a. One pair of depth or one pair of custom-molded therapeutic shoes per calendar year for members diagnosed with diabetes 1) The shoes must be prescribed, fitted and furnished by a podiatrist or other qualified individual (e.g., a pedorthist, orthotist or prosthetist) 2) The shoes must meet this policy’s definition for depth or custom-molded shoes (see Section E) 3) The managing physician, who is a doctor of medicine (M.D.), doctor of podiatric medicine (D.P.M.) or a doctor of osteopathy (D.O.) and who is responsible for diagnosing and treating the member’s systemic condition, must do all the following: a) Document in the medical record that the member has diabetes b) Certify that the member is being treated under a comprehensive plan of care for his/her diabetes c) Certify that the member needs therapeutic shoes d) Document in the member’s record that the member has one or more of the following conditions: (1) Peripheral neuropathy with the evidence of callus formation (2) History of previous ulceration, pre-ulcerative calluses, foot deformity, or previous amputation of the foot or part of the foot (3) Vascular insufficiency Note: A pair of therapeutic shoes are covered even if only one foot suffers from diabetic foot disease (each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected). b. Inserts 1) The member must have the appropriate footwear to accommodate the insert 2) Limitations a) Three (pairs) inserts per calendar year for custom-molded shoes (including inserts provided with the shoes) b) Four (pairs) inserts per calendar year for depth shoes (including the non-customized removable inserts provided with the shoes) c. Modifications of custom-molded or depth shoes (e.g., wedges, offset heels, Velcro closures, inserts for missing toes, etc.) instead of obtaining a pair of inserts in any combination.

Also see Foot Care and Podiatry Services, DME, Prosthetics, Corrective Appliances and Medical Supplies Grid, and Diabetic Management, Services and Supplies D.

NOT COVERED 1.

Foot orthotics are not a covered benefit unless the member meets the above diabetic foot disease criteria or as required by State Mandates or Market Plan Enhancement (see Sections A and B), in which case, one pair of orthotics is covered per calendar year. a. Examples include, but are not limited to: 1) Heel cups 2) Shoe lifts 3) Shoe inserts

2. 3. 4. 5. E.

DEFINITIONS 1. 2.

3.

4.

5.

6. 7.

F.

4) Foot pads 5) Custom-made polypropylene with plastic or rigid plastic foot orthotics Therapeutic shoes except as described above in Section C Orthopedic shoes or other supportive devices for the feet except as described above Orthopedic shoes for subluxations of the foot Supportive devices for the feet other than described above in Section C

Prosthetic Shoe: A device used when all or a substantial portion of the forefoot (front part) is missing. Custom-Molded Shoes: Shoes that are constructed over a positive model of the member’s foot; made from leather or other suitable material of equal quality, have removable inserts that can be altered or replaced as the member’s condition warrants; and have some form of shoe closure. Depth Shoes: Shoes that have a full-length heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth used to accommodate custom molded or customized inserts, are made of leather or other suitable material of equal quality, have some form of foot closure, and are available in full and half sizes with a minimum of 3 widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard last sizing schedule (the numerical shoe sizing system used for shoes sold in the United States or its equivalent). Foot Orthotics: Shoe inserts that are intended to correct foot function and minimize stress forces that could ultimately cause foot deformity and pain by altering slightly the angles at which foot strikes a walking or running surface. Inserts: Total contact, multiple density, removable inlays that are directly molded to the patient’s foot or a model of the patient’s foot and that are made of suitable material with regard to the patient’s condition. Orthopedic Shoe: A shoe that prevents or corrects foot deformity. Peripheral Neuropathy: A degenerative condition of the nervous system involving the skin of the extremities.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SURGERY

TITLE:

Cosmetic, Reconstructive or Plastic Surgery

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 8/6/99

Effective Date: 1/1/00

Review Date: 10/22/99, 11/3/00, 7/12/01, 12/06/01, 06/20/02,, 3/20/03, 6/18/03, 12/15/04, 5/19/05, 5/10/07, 3/13/08, 5/22/08, 6/23/09, 9/2/10, 11/15/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: S-006

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS Women's Health and Cancer Rights Act of 1998, § 713 (a): "In general, a group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for (1) reconstruction of the breast on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce symmetrical appearance; and (3) prostheses and physical complications, all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient."

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Federal Employees Health Benefits (FEHB) EOC: The following reconstructive surgery is covered: (1) Surgery to correct a condition caused by injury or illness if: (a) the condition produced a major effect on the member’s appearance and (b) the condition can reasonably be expected to be corrected by such surgery (2) Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are:

protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. 1.

Reconstructive surgery only when needed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function or create a normal appearance to the extent possible. (see Medical Necessity policy) a. Examples include, but are not limited to: 1) Surgery to restore body function related to a congenital defect 2) Surgery that is incident to a several stage treatment plan following a trauma (e.g., a serious auto accident, severe burns) for which medically necessary reconstructive surgery is necessary to improve functional impairment, as determined by member's provider/practitioner 3) Release of scar contracture causing pain or impairing function 4) Breast reduction surgery (mammoplasty) based on medical necessity. See Medical Management Guideline: Breast Reduction (click Internal, Provider Portal or Member). 5) Treatment of gynecomastia, including: a) Evaluation for pathology/etiology b) Breast surgery for abnormal pathology See Medical Management Guideline: Gynecomastia (click Internal, Provider Portal or Member). 6) Surgery to correct hypospadias

Notes: • Also see Surgery: Post Mastectomy policy and Breast Reduction, Gynecomastia, Breast Repair/Reconstruction Not Following Mastectomy, Cosmetic and Reconstructive Services, Breast Reduction, Blepharoplasty, Panniculectomy and Body Contouring Procedures, and Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis Medical Management Guidelines Medical Management Guidelines (click Internal, Provider Portal or Member). D.

NOT COVERED 1.

2

3.

When there is another more appropriate surgical procedure that has been offered to the member as determined or defined by UnitedHealthcare or designee or when only minimal improvement in the member’s appearance is expected to be achieved. Non-medically necessary cosmetic or reconstructive surgery that is performed only to improve appearances and is not intended to improve the physical functioning of a malformed body part(s) (see Medical Necessity policy) Non-medically necessary elective or voluntary enhancement procedures or services, supplies and medications a. Examples include, but are not limited to: 1) Services related to hereditary pattern baldness, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance 2) Breast surgery only for the purpose of creating symmetrical breasts (excluding post mastectomy and post lumpectomy) 3) Tattoo removal, dermabrasion or liposuction

4) 5) 6) 7) 8) 9) 10) 11)

Nasal reconstruction without a confirmed disease process Repair of a cleft palate, after the speech development phase, to improve the voice rather than correct a swallowing problem. Reconstructive breast surgery following a non-medically necessary mastectomy or lumpectomy. (see Surgery: Post Mastectomy policy) Removal and/or replacement of breast implants for non-medical reasons Replacement of breast prosthesis and the prosthesis itself following cosmetic breast augmentation mammoplasty. (see Surgery: Post Mastectomy policy) Reduction mammoplasty that is not medically necessary Cosmetic mammoplasty Procedures, services, medications and supplies related to sex transformations for adults. (except as indicated in Section B)

See also Dental Care, Surgery: Orthognathic and Medical Necessity policies E.

DEFINITIONS Cleft Palate: A congenital opening between two parts of the palate often associated with cleft lip. Congenital Defect: A condition present at birth. Cosmetic Surgery: Cosmetic or reconstructive surgery used to alter and improve the member's physical appearance or to improve the member's self-esteem and which provides no improvement to a functional impairment. Gynecomastia: Enlargement of the male breast. Hypospadias: A congenital defect in which the urethra opens on the ventral (bottom) surface of the penis rather than on the glans. Mammoplasty: Surgery to the breast(s), including reduction (reduces the breast size) or augmentation (increases the breast size with implants). Mastectomy: Medically necessary surgical removal of the breast. For the purposes of this policy, mastectomy includes the excision of a breast or of a lump. Reconstructive Surgery: Surgery performed to reshape abnormal structures of the body when necessary to improve functional impairment. An example of reconstructive surgery would be the repair of a congenital defect, such as cleft-lip or palate, which impedes functional ability.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SURGERY

TITLE:

Orthognathic Surgery

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 10/22/99

Effective Date: 02/01/13

Review Date: 6/18/03, 2/2/05, 12/7/06, 12/16/08, 12/16/09, 2/16/11, 12/20/11, 12/27/12

Policy Number: S-010

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: Depending on the member's benefit plan, some members may not have coverage for orthognathic surgery. Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefit (SOB) to determine the coverage eligibility. 1.

Orthognathic surgery is covered only when both of the following criteria are met: a. The surgery is medically necessary for correction of a condition that adversely affects or prevents the following normal functions that involve the lower or upper jaw, face or temporomandibular joint 1) Mastication a) For surgical intervention member must exhibit malocclusion that impedes his/her ability to form a food bolus that can be swallowed 2) Breathing 3) Drinking 4) Swallowing 5) Speech b. Dental, orthodontic or other treatment measures have failed

Notes: • Refer to the Medical Management Guidelines: Orthognathic Surgery (click Internal, Provider Portal or Member). • Also see Dental Care and Oral Surgery, Surgery: Cosmetic, Reconstructive or Plastic, Sleep Apnea and Treatment of TMJ Disorders policies D.

NOT COVERED 1.

2.

3.

4.

5. 6. E.

DEFINITIONS 1.

2. 3. 4.

5. 6.

F.

Cosmetic surgery or treatment provided solely to improve the member's appearance and not intended to improve the physical functioning of a malformed body part(s) (see Surgery: Cosmetic, Reconstructive or Plastic and Medical Necessity policies) Reconstruction of the jawbone or supporting tissues to provide a better fit for dentures or other mouth prostheses or reconstruction of the jawbone following services that were originally dental in nature Application of dental/orthodontic devices/appliances, whether or not it accompanies oral and/or orthognathic surgery, except as addressed in the Treatment of Temporomandibular Joint (TMJ) Disorders policy (see Treatment of TMJ Disorders policy) Surgery to correct malocclusion or any abnormality resulting from malocclusion under either of the following circumstances: a. The malocclusion can be corrected by other measures b. The malocclusion is not accompanied by any demonstrable functional impairments Dental implants Bone grafts for preparation of dental implants

Cosmetic Surgery: Cosmetic or reconstructive surgery used to alter and improve the member's physical appearance or to improve the member's self-esteem and which provides no improvement to a functional impairment. Dental/Orthodontic Devices/Appliances: Any device used to influence growth or the position of teeth and jaws. (e.g., braces, retainers, night guards, oral splints) Malocclusion: Any deviation from a physiologically acceptable contact of opposing dentitions. Dental Implant: A device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement; endosteal (endosseous); eposteal (subperiosteal); transosteal (transosseous). (American Dental Association Glossary) Dental Prosthesis An artificial device that replaces one or more missing teeth. (American Dental Association Glossary) Orthognathic Surgery: Involves several reconstructive procedures to correct deformities of the jaws and facial skeleton.

REFERENCES 1.

American Association of Orthodontists - Orthodontic Glossary

SignatureValue™ Benefit Interpretation Policy SUBJECT:

SURGERY

TITLE:

Post Mastectomy Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 02/01/13

Review Date: 7/12/01, 6/18/03, 10/20/05, 5/16/06, 11/6/07, 3/13/08, 12/16/08, 12/16/09, 11/15/10, 12/20/11, 12/27/12

Policy Number: S-009

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

2.

Women's Health and Cancer Rights Act of 1998, § 713 (a): “In general - a group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for (1) all stages of reconstruction of the breast on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce symmetrical appearance; and (3) prostheses and physical complications all stages of mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter. Title 36 Oklahoma Statues §6060.5 - "Oklahoma Breast Cancer Patient Protection Act" A. This section shall be known and may be cited as the "Oklahoma Breast Cancer Patient Protection Act." B. Any health benefit plan that is offered, issued or renewed in this state on or after January 1, 1998, that provides medical and surgical benefits with respect to the treatment of breast cancer and other breast conditions shall ensure that coverage is provided for not less than forty-eight (48) hours of inpatient care following a mastectomy and not less than twentyfour (24) hours of inpatient care following a lymph node dissection for the treatment of breast cancer. C. Nothing in this section shall be construed as requiring the provision of inpatient coverage where the attending physician in consultation with the patient determines that a shorter period of hospital stay is appropriate. D. Any plan subject to subsection B of this section shall also provide coverage for reconstructive breast surgery performed as a result of a partial or total mastectomy. Because breasts are a

3.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

paired organ, any such reconstructive breast surgery shall include coverage for all stages of reconstructive breast surgery performed on a nondiseased breast to establish symmetry with a diseased breast when reconstructive surgery on the diseased breast is performed, provided that the reconstructive surgery and any adjustments made to the nondiseased breast must occur within twenty-four (24) months of reconstruction of the diseased breast. E. In implementing the requirements of this section, a health benefit plan may not modify the terms and conditions of coverage based on the determination by an enrollee to request less than the minimum coverage required pursuant to subsections B and D of this section. F. A health benefit plan shall provide notice to each insured or enrollee under such plan regarding the coverage required by this section in the plan's evidence of coverage, and shall provide additional written notice of the coverage to the insured or enrollee as follows: 1. In the next mailing made by the plan to the employee; 2. As part of any yearly informational packet sent to the enrollee; or 3. Not later than December 1, 1997; whichever is earlier. G. As used in this act, "health benefit plan" means any plan or arrangement as defined in subsection G of Section 6060.3 of this title. H. The Insurance Commissioner shall promulgate any rules necessary to implement the provisions of this section. Title 36 Oklahoma Statutes §6060.3 (G) - "Health Benefit Plan" Defined……………… As used in this section, "health benefit plan" means individual or group hospital or medical insurance coverage, a not-for-profit hospital or medical service or indemnity plan, a prepaid health plan, a health maintenance organization plan, a preferred provider organization plan, the State and Education Employees Group Health Insurance Plan, and coverage provided by a Multiple Employer Welfare Arrangement (MEWA) or employee self-insured plan except as exempt under federal ERISA provisions.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

When a member elects breast reconstruction following a medically necessary mastectomy (total or partial) or lumpectomy, coverage is to be provided as determined through consultation between the attending physician and the member, and includes: a. Reconstructive breast surgery of the affected breast 1. When performed for tumor or any neoplastic (cancer) disease or 2. Trauma or injuries to the breast e.g., crush injury or severe burn b. Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance c. External breast prosthesis d. Initial breast implant e. Replacement breast implants when medically necessary f. Nipple tattoo for reconstructive purposes

g. h. i.

Tissue expansion Regional tissue transfer Treatment of physical complications resulting from the mastectomy or lumpectomy, including lymphedema. Treatment for lymphedema may include: 1) Lymphedema appliances/sleeves (See DME, Prosthetics, Corrective Appliances and Medical Supplies Grid) Note: CDP is considered a medical treatment rather than part of rehabilitation therapy, therefore, CDP is not subject to rehabilitation/therapy copayment nor benefit maximum.

Notes: • See Section A: Reconstruction of a congenital deformity of the breast (absence of the breast or asymmetrical breasts) is covered when required by State Mandate. • Also see Surgery: Cosmetic, Reconstructive or Plastic and DME, Prosthetics, Corrective Appliances and Medical Supplies policies and Medical Management Guideline: Breast Reconstruction Post Mastectomy (click Internal, Provider Portal or Member). D.

NOT COVERED 1.

E.

DEFINITIONS 1. 2.

F.

Services for members who have not had a medically necessary mastectomy or lumpectomy and who are requesting surgery only for the purpose of creating symmetrical breasts

Mastectomy: For the purposes of this policy, mastectomy includes the excision of a breast or lump. Reconstructive Surgery: Surgery performed to reshape abnormal structures of the body.

REFERENCES 1.

Women's Health and Cancer Rights Act of 1998, § 713 (a)

SignatureValue™ Benefit Interpretation Policy SUBJECT:

TELEMEDICINE/TELEHEALTH SERVICES

TITLE:

Telemedicine/Telehealth Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 2/2/05

Effective Date: 02/01/13

Review Date: 12/7/06, 12/16/08, 12/16/09, 12/20/11, 12/27/12

Policy Number: T-005

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Telemedicine/telehealth services only when all of the following criteria are met: a. Member requires services that are usually provided by direct contact with the provider b. Member resides outside of a Metropolitan Statistical Area (MSA) (See Section E - Definitions) c. Services are authorized by the member's contracting/participating medical group or UnitedHealthcare Also see Physician Services policy

D.

NOT COVERED 1.

E.

Telemedicine/Telehealth services when criteria in Section C is not met, unless required by State Mandate

DEFINITIONS

1.

2.

3.

F.

Metropolitan Statistical Area (MSA): A Core Based Statistical Area associated with at least one urbanized area that has a population of at least 50,000. The Metropolitan Statistical Area comprises the central county or counties containing the core, plus adjacent outlying counties having a high degree of social and economic integration with the central county as measured through commuting. Telemedicine: The use of interactive audio, video, or other electronic media to deliver health care. This includes the use of electronic media for diagnosis, consultation, treatment, transfer of medical data, and medical education. This term does not include services performed using a telephone or facsimile machine. Telehealth: A health service, other than a Telemedicine, delivered by a licensed or certified health professional acting within the scope of the health professional's license or certification who does not perform a Telemedicine medical service that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including: 1. compressed digital interactive video, audio, or data transmission; 2. clinical data transmission using computer imaging by way of still-image capture and store and forward; and 3. other technology that facilitates access to health care services or medical specialty expertise.

REFERENCES 1. 2. 3. 4.

U.S. Office of Management and Budget - Standards for Defining Metropolitan and Micropolitan Statistical Areas; Notice TX Titles 2. Public Utility Regulatory Act Subtitle C. Telecommunications Utilities Chapter 57. Distance Learning and other Advanced Services The American Telemedicine Association http://www.atmeda;org/news/definition/html The Association of Telehealth Service Providers http://www.atsp.org

SignatureValue™ Benefit Interpretation Policy SUBJECT:

TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS

TITLE:

Treatment of TMJ Disorders

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 5/3/01, 6/18/03, 3/17/04, 5/4/06, 7/10/06, 5/22/08, 6/23/09, 6/22/10, 9/2/10, 06/21/11, 06/28/12, 06/27/2013

Policy Number: T-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS . None

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: For member specific coverage and limitations for the treatment of TMJ, refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefit (SOB) or contact the Customer Service Department. Medically necessary treatment for temporomandibular joint (TMJ) disorders that result in severe functional impairment and limited jaw movement caused by a medical condition. See Medical Management Guidelines: Mandibular Disorders (click Internal, Provider Portal or Member). D.

NOT COVERED 1.

Treatment of functional impairments that are caused by a dental condition

2.

3. 4. 5. 6. 7. E.

Treatment methods that are recognized as dental procedures, including but not limited to the following: a. Extraction of teeth b. Crowns, fillings, dental implants or dentures c. Application of non-removable orthodontic appliances Treatment of malocclusion or any abnormality resulting from malocclusion Behavior modification Full mouth reconstruction Anticipated conditions that occur as a component of a not covered service, such as orthodontic treatments for a dental condition or jaw wiring for the treatment of obesity Biofeedback for the treatment of TMJ

DEFINITIONS Severe Functional Impairment: As they relate to TMJ disorders, severe functional impairments are demonstrable physiologic conditions that adversely affect the normal functions of the temporomandibular joint and lower and upper jaw (e.g., mastication, breathing, swallowing, drinking and speech). Temporomandibular Joint (TMJ): The temporomandibular joint connects the mandible, or jawbone, to the temporal bone of the skull. TMJ Disorders: Abnormal conditions characterized by facial pain, limited or abnormal range of motion, limited jaw movement and mandibular (lower jaw) dysfunction caused by a defective or damaged temporomandibular joint.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy

SUBJECT:

TRANSPLANTS

TITLE:

Organ and Tissue Transplants

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 5/7/99

Effective Date: 02/01/13

Review Date: 3/1/01, 7/12/01, 12/6/01, 3/21/02, 6/20/02, 3/20/03, 3/17/04, 12/15/04, 12/5/05, 5/10/07, 12/16/08, 12/16/09, 12/20/11, 12/27/12, 09/20/13

Policy Number: T-004

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Statutes Title 63s. 2505(G) (2): A health maintenance organization or prepaid health plan shall provide comprehensive health services in a manner that is reasonably geographically convenient to residents of the service area for which it seeks a license.

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

Note: UnitedHealthcare shall intermittently review new developments in medical technology based on scientific evidence to determine if the list of covered transplants should be revised. 1.

2.

3.

4.

Human organ and tissue transplants are limited to non-experimental procedures that are determined to be medically necessary (see Medical Necessity policy). Coverage is provided for the pre-and post-operative medical, surgical, hospital services and medically necessary ambulance transportation to the UnitedHealthcare Designated Facility. All transplant procedures must be performed by a UnitedHealthcare Designated Facility. When the transplant recipient is a UnitedHealthcare member, reasonable and necessary services of the donor solely for the transplant procedure are covered if the donor does not have insurance or the donor's primary insurance does not cover donor hospital services (the donor does not need to be a UnitedHealthcare member for transplant services to be covered) Listing at two UnitedHealthcare Designated Facilities a. Dual listing is allowed only when organ procurement agency used is different b. Member is financially responsible for all costs associated with the 2nd transplant evaluation. Note: UnitedHealthcare will pay for the transplant surgery, donor inpatient services and surgery, and post-transplant services at the facility which performs the transplant. Pre-transplant testing and evaluation, including histocompatibility testing for the transplant

5. 6. 7. 8. 9. 10.

D.

NOT COVERED 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11. 12. E.

recipient and donor when the intended transplant recipient is a UnitedHealthcare member. The testing of immediate blood relatives to determine the compatibility of bone marrow and stem cells is limited to immediate blood relatives who are sisters, brothers, parents and natural children. Organ acquisition from cadaver or live donor An oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to transplant surgery Outpatient post-transplant, immunosuppressive drug therapy only if the member has a supplemental pharmacy benefit Storage costs of any organ or bone marrow only as part of an authorized treatment protocol as determined by the UnitedHealthcare Designated Facility Medical Director or designee Bone marrow and stem cells donor search and testing (Note: Specific requirements and limitations apply, see the member’s EOC/SOB) Transportation, food and housing expense of the member and one escort to the UnitedHealthcare Designated Facility (Note: Specific requirements and limitations apply, see the member’s EOC/SOB)

Artificial heart implantation Non-human organ transplantation Equipment and medication that is experimental/investigational and/or not medically necessary (see Medical Necessity policy) Services for which government funding or other insurance coverage is available Storage costs of any organ or bone marrow unless criteria in C.8 are met Transplant services, including donor costs, when the transplant recipient is not a UnitedHealthcare member Transplantation performed in a non- UnitedHealthcare Designated Facility Transportation of any potential donor for typing and matching Unauthorized or not prior authorized organ procurement and transplant related services Transportation, food and housing expenses of the member a. When the member is not receiving medically necessary transplant services b. Above and beyond the allowed benefit for the member (Note: Refer to the member’s EOC/SOB) Transportation and other non-clinical expenses of a living donor Transplant evaluation at the 2nd facility

DEFINITIONS 1. 2. 3.

4.

Donor: A person who undergoes a surgical procedure for the purpose of donating either a body organ or body tissue for transplant surgery. Histocompatibility Testing: Testing that involves the matching or typing of the human leukocyte antigen in preparation for organ/tissue transplantation. Designated Facility (Includes UnitedHealthcare National Preferred Transplant Network [NPTN]): A facility that has entered into an agreement with UnitedHealthcare, or with an organization contracting on UnitedHealthcare’s behalf, to render covered services for the treatment of specified diseases or conditions. A Designated Facility may or may not be located within the service area. The fact that a hospital is a participating/contracting hospital does not mean that it is a Designated Facility. Transplant Evaluation (Bone Marrow): Begins with initial consult with transplant physician and ends upon acceptance or denial into the transplant program. services include, but are not

5.

6.

F.

limited to: • Consultation with transplant physician(s), psychiatrist(s), specialist(s), transplant coordinator(s), social services • Hematology, blood banking, serology, chemistry, histocompatibility testing according to Member’s Benefit Program • X-rays, pulmonary function tests, skin tests, leukopheresis consultation, CT scan, tissue typing, MRI • Restaging of disease • Inpatient or outpatient, including professional, room and board, nursing, inpatient pharmacy and all other ancillary services Transplant Evaluation (Solid Organ): Pre-Transplant medically necessary services required to assess and evaluate the Member to determine acceptance to transplant program. This phase ends upon acceptance or denial into the transplant program. Services include, but are not limited to: • Consultation with surgeon(s), psychiatrist(s), specialist(s), transplant coordinator(s), social services • Hematology, blood banking, serology, chemistry, histocompatibility • X-rays, pulmonary function tests, skin tests, leukopheresis consultation, CT scan, tissue typing, MRI • Inpatient or outpatient services, including professional, room and board, nursing, inpatient pharmacy and all other ancillary services Transplant Facility Authorized by UnitedHealthcare: A facility that is licensed in the State in which it operates; certified by Medicare as a transplant facility for a specific organ transplant; and authorized by the Company to perform transplant services under the Policy provisions.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

VETERANS ADMINISTRATION (VA)

TITLE:

Veterans Administration (VA) and Coordination of VA Benefits

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 11/3/00, 7/12/01, 12/5/02, 9/17/03, 10/20/05, 8/28/07, 5/22/08, 2/18/09, 11/15/10, 6/21/11, , 06/27/2013

Policy Number: V-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS None

B.

STATE MARKET PLAN ENHANCEMENTS None

C.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2.

For members who are non-VA eligible: a. Emergency services 1) UnitedHealthcare will cover emergency and out-of-area urgently needed care provided by a VA facility in accordance with the member's emergency services benefits (such services are considered to be out-of network). When stable for transfer, the member must be transferred to his/her contracted UnitedHealthcare facility for continued care. Note: See the Emergency and Urgent Services policy for the definitions of emergency and urgently needed services. For claims received 5/01/08 and after For members who are VA eligible (i.e., veterans, retired military personnel and eligible dependents): a. Emergency services

1)

UnitedHealthcare will cover emergency, out of area urgently needed services provided by a VA or other Government Medical Facilities, in accordance with the member's emergency services benefits. b. Skilled nursing facility (SNF) care 1) Continued SNF care is covered when the member exhausts his/her VA SNF benefit and when both of the following are met: a) Criteria for SNF care are met b) The skilled level determination is made by the member’s UnitedHealthcare physician or the UnitedHealthcare Medical Director and the care is directed, furnished and authorized by the member’s PMG/IPA or UnitedHealthcare. Note: VA SNF days (that are authorized and paid by VA) do not count against the UnitedHealthcare SNF benefit. Members who exhaust the UnitedHealthcare SNF benefit may qualify for continued SNF coverage through VA. See Emergency and Urgent Services, Skilled Nursing Facility [SNF] Care, Inpatient Mental Health, Outpatient Mental Health, Organ and Tissue Transplants, and Chemical Dependency/Substance Abuse Rehabilitation D.

NOT COVERED 1. 2.

3.

E.

Services obtained in a VA facility by UnitedHealthcare members who are VA eligible when: a. VA authorizes services that are not a covered benefit. Coverage for service-related (service-connected) services. Examples include but are not limited to: military service-related post traumatic stress disorder (PTSD) treatment, Gulf War syndrome, treatments for Agent Orange. Non emergency services, urgent services in area or non-urgent (routine services) unless the services are authorized and directed by the member’s PMG/IPA or UnitedHealthcare.

DEFINITIONS Emergency Services: See Sections A & B of the Emergency and Urgent Services policies for statespecific definition Urgent Services: See Sections A & B of the Emergency and Urgent Services policies for state-specific definition

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

VISION

TITLE:

Vision Care and Services

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 4/2/99

Effective Date: 1/1/00

Review Date: 9/1/00, 5/3/01, 3/21/02, 9/19/02, 3/20/03, 6/23/04, 12/15/04, 8/17/06, 12/7/06, 5/10/07, 2/14/08, 4/15/09, 4/21/10, 4/19/11, 04/26/12, 09/21/12, 04/25/13

Policy Number: V-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

Oklahoma Administrative Code, 310:655-5-1(11): Comprehensive services shall include medically necessary eye care services for detection and treatment of diseases or injury to the eye.

Members may have supplemental coverage for frames and lenses. Refer to the member’s EOC/SOB or contact the Customer Service Department to determine coverage eligibility.

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

Eye examinations a. Vision screening services to determine the need for vision correction that are performed in the Primary Care Physician's office at the time of the member's routine health assessment. This screening may include use of a standard eye chart (Snellen chart) or its equivalent. b. PCP may refer to an optometrist or ophthalmologist with a complaint or symptoms of an eye disease or injury c. Routine refraction every 12 months to determine the need for corrective lenses (refractive error), including written prescription for eyeglasses (Note: Members may have supplemental coverage for frames and lenses. Refer to the member’s EOC/SOB or contact the Customer Service Department to determine coverage eligibility.)

2.

3.

4. 5.

6. 7.

d. Annual diabetic retinal examination for members with diabetes Refractive lenses a. One pair of eyeglasses or contact lenses are covered after each cataract surgery, with the insertion of a conventional intraocular lens (IOL). Eyeglasses or contact lenses must be obtained through the participating/contracting medical group/provider rather than through the member’s supplemental vision benefit. b. For members who are aphakic and do not have an IOL, either because of surgery or congenital absence, the following lenses or combination of lenses are covered when determined to be medically necessary. Prosthetic lenses must be obtained through the participating/contracting medical group/provider rather than through the member’s supplemental vision benefit. 1) Prosthetic bifocal lenses in frames (prescription eyeglasses); 2) Prosthetic lenses in frames (prescription eyeglasses) for far vision and lenses in frames for near vision (prescription eyeglasses); or 3) When contact lenses for far vision are prescribed, coverage includes: contact lenses and prosthetic lenses in frames (prescription eyeglasses) for near vision, and prosthetic lenses in frames (prescription eyeglasses) for when the contacts are removed (i.e., coverage for contacts for far vision, eyeglasses for near vision to be worn with the contacts, and eyeglasses for far vision for when the contacts are removed). Note: Prosthetic lenses (prescription eyeglasses) that have ultraviolet absorbing or reflecting properties may be covered in lieu of the regular (un tinted) prosthetic lenses mentioned in 1), 2) and 3) above if it has been determined that such lenses are medically reasonable and necessary for the individual patient.) FDA-approved hydrophilic contact lens used as moist corneal bandages are covered for the treatment of acute or chronic corneal pathology. Contact lenses must be obtained through the participating medical group/provider rather than through the member’s supplemental vision benefit. a. Bullous keratopathy b. Dry eyes c. Corneal ulcers and erosion d. Keratitis e. Corneal edema f. Descemetocele g. Corneal ectasis h. Mooren's ulcer i. Anterior corneal dystrophy j. Neurotrophic keratoconjunctivitis Hard/rigid contact lenses for the treatment of keratoconus Verteporfin for ocular photodynamic therapy (OPT) only when furnished intravenously incident to a physician's service when medical criteria are met. Refer to the OptumRx Prior Authorization Guidelines: Visudyne (Verteporfin). Vision training services are covered only when medically reasonable and necessary to treat a disease or injury of the visual system, such as diplopia caused by an ocular nerve palsy. Cataracts are considered a medical condition and surgery for repair is covered.

D.

NOT COVERED 1. 2. 3. 4.

5. 6. 7. 8. 9. 10. 11.

12. 13. 14.

E.

Sunglasses (e.g., cataract sunglasses) Eyeglasses and/or contact lenses for cosmetic purposes only Services/materials connected with contact lenses, plano glasses (non prescription), low vision aids or two pairs of bifocals Ocular exercises, visual training, vision training, orthoptics, and any associated supplemental testing when prescribed solely for the purpose of improving visual acuity, or to reduce dependence on corrective lenses. Services/materials provided by a nonparticipating provider or provided by another vision or medical plan Frames, lenses or contact lens replacements after initial contact lens provided in connection with post cataract surgery with IOL implant Non-conventional/specialized IOL implants (e.g., presbyopia -correcting IOLs such as Crystalens™, AcrySof RESTOR™, ReZoom™) Frames, lenses and/or contact lenses unless member has supplemental vision benefits or the member has a medical diagnosis, as described above Eye exam/corrective eyewear required by an employer or conditions covered by Workers’ Compensation K-readings for fitting of non medically necessary contact lenses Surgery for presbyopia, astigmatism and myopia only for the purpose of improving refraction a. Examples include, but are not limited to, radial keratotomy , keratomileusis (e.g., LASIK), keratophakia Contact lens cleaning solution and normal saline for contact lenses Scratch resistant coating and progressive lenses Hydrophilic contact lenses are not covered when used in the treatment of non-diseased eyes with spherical ametropia, refractive astigmatism and/or corneal astigmatism.

DEFINITIONS 1. 2.

3. 4. 5. 6. 7. 8.

Aphakic: The absence of the lens of the eye, either due to surgical removal or congenital absence. Ocular Photodynamic Therapy (OPT): A treatment for age-related macular degeneration (AMD), OPT combines a light-sensitive medication and laser to destroy diseased tissue and abnormal blood vessels in the eye. Orthoptics: The study and treatment of a member’s defective vision involving the use of both eyes at the same time, of defects in the action of eye muscles or of irregular visual habits. Presbyopia: Age associated type of refractive error that results in a progressive loss of ability to focus on objects at near distance or close-up. Prosthetic Lenses: Artificial devices used to replace the human eye lens that was removed during a surgical procedure such as cataract removal. Refraction: Determination of the optical state of the eye and the basis for prescribing glasses and contact lenses. Verteporfin: A benzo porphyrin derivative and intravenous lipophilic photosensitive drug with an absorption peak of 690mm. Vision Screening: Services to determine the health of the Member’s eyes and possible need for vision correction performed in the Primary Care Physician's office at the time of the member's routine health assessment. This screening may include use of a standard eye chart (Snellen chart) or its equivalent. A

specialist referral for further testing may be necessary if there a medical reason or unclear diagnosis.

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

WEIGHT ALTERATION PROGRAMS

TITLE:

Weight Gain or Weight Loss Programs

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 6/4/99

Effective Date: 1/1/00

Review Date: 12/5/02, 1/14/04, 3/17/04, 5/4/06, 7/16/08, 9/1/09, 9/2/10, 8/16/11, 08/23/12, 08/22/13

Policy Number: W-001

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1. D.

None

NOT COVERED 1. 2.

Weight loss or weight gain programs Prescription drugs to treat obesity unless otherwise covered under the supplemental pharmacy benefit. 3. Examples include, but are not limited to: a. Dietary evaluations and counseling except as provided by the Primary Care Physician b. Exercise programs c. Behavioral modification programs d. Food and food supplements e. Vitamins and other nutritional supplements associated with weight gain or weight loss Also see Treatment of Morbid Obesity policy

E.

DEFINITIONS 1. Morbid Obesity: Morbid obesity exists in patients that have a Body Mass Index (BMI) > 40 or a BMI > 35 with co-morbid conditions. BMI is calculated as weight in kilograms per height in meters squared (kg/m2).

F.

REFERENCES

SignatureValue™ Benefit Interpretation Policy SUBJECT:

WHEELCHAIRS

TITLE:

Wheelchairs and Accessories

MARKET:

UnitedHealthcare of Oklahoma, Inc.

Approval Date: 7/2/99

Effective Date: 1/1/00

Review Date: 1/5/01, 3/21/02, 5/5/04, 5/4/06, 5/22/08, 6/23/09, 6/17/10, 9/2/10, 6/21/11, 06/28/12, 06/27/2013

Policy Number: W-002

REMINDER: Covered benefits are listed in three (3) Sections - A, B and C. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage, limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.

A.

FEDERAL/STATE MANDATED REGULATIONS 1.

B.

STATE MARKET PLAN ENHANCEMENTS 1.

C.

None

None

COVERED BENEFITS IMPORTANT NOTE: Covered benefits are listed in Sections A, B and C. Always refer to Sections A and B for additional covered benefits not listed in this Section.

1.

2. 3.

D.

The following are covered when criteria are met. See Mobility Assistive Equipment Clinical Criteria for coverage criteria. Wheelchairs are covered only if the member has a DME benefit. a. Standard wheelchair b. Lightweight wheelchair c. Specially sized wheelchair d. Electric wheelchair e. Power operated vehicle (POV Repairs, replacements and maintenance according to specific criteria - refer to DME, Prosthetics, Corrective Appliances and Medical Supplies policy Battery replacement (purchased equipment) only when the member owns or is purchasing (not renting) the electric wheelchair or POV

NOT COVERED

1. 2. 3. 4. 5. 6. 7. 8. 9. E.

DEFINITIONS 1. 2.

3. 4.

F.

Deluxe items or features Wheelchair upgrades that are beneficial primarily in allowing the member to perform leisure or recreational activities POVs for members who are capable of ambulation within the home, but require a power vehicle for movement outside of the home POVs that are primarily used to allow the member to perform leisure or recreational activities Repairs on rented DME items (DME provider is responsible for such repairs) A wheelchair provided at the same time or subsequent to coverage of a POV Items purchased for comfort or added convenience for the member or the member's caretaker Routine periodic maintenance/servicing for which the owner is responsible (e.g., testing, cleaning, regulating and checking equipment) Replacement of a wheelchair due to malicious damage, neglect or abuse

Standard Wheelchair: A wheelchair that weighs greater than 36 lbs. Standard Hemi-wheelchair: A wheelchair that weighs greater than 36 lbs., but the seat is lower to the floor in order to accommodate shorter stature or for a patient who self-propels with their feet on the floor. Lightweight Wheelchair: A wheelchair that weighs less than 36 lbs. High Strength Lightweight Wheelchair: A wheelchair that weighs less than 34 lbs and has a lifetime warranty on the side frames and cross braces.

REFERENCES