State of Illinois - HealthLink

c. Patch: Ortho Evra
d. Depo-Provera injection
e. Implant: Norplant and Etonogestrel IUD
35. Compression hose are covered as non-surgical treatment of varicose veins. A diagnosis of
varicose veins is required for this benefit, and this is limited to two pair per plan year. In
addition, compression hose are covered after a surgical procedure and no longer than six
months after the procedure with a limit of two per covered period.
36. Jobst or Gradient stockings are covered with a diagnosis of lymphedema.
37. Cochlear implants will be covered under the regular medical plan, not the Hearing Aid
benefit, when deemed medically necessary.
38. Nutritional Counseling/Dietitian will include nutritional evaluation and counseling as
medically necessary for the management of any medical condition for which appropriate diet
and eating habits are essential to the overall treatment program when prescribed by a physician
and provided by a licensed health care professional (e.g., a registered/clinical dietitian). A letter
of medical necessity from the prescribing physician is required. Coverage shall be limited to
one nutritional counseling session per primary medical condition per lifetime not to exceed 10
classes per session. Conditions for which nutritional evaluation and counseling may be
considered medically necessary include, but are not limited to the following:
Anorexia Nervosa/Bulimia Celiac Disease Cardiovascular Disease
Crohn’s Disease Hyperlipidemia Liver Disease
Malabsorption Syndrome Metabolic Syndrome Multiple or Severe Food Allergies
Nutritional Deficiencies Gastric Bypass/Lap Band Renal Failure
Ulcerative Colitis Cancer High Cholesterol
High Blood Pressure Diabetes
Specifically excluded is nutritional counseling solely for the management of the following
conditions:
a. Attention-Deficit/Hyperactivity Disorder
b. Chronic Fatigue Syndrome
c. Idiopathic Environmental Intolerance (casual connection between environmental
chemicals, foods and/or drugs)
39. Anesthesia coverage for dental services when the medical condition is significant enough
to impact the need to provide anesthesia services, and when other alternative type of
anesthesia, sedation or analgesia are not appropriate and the following requirements exist:
a. The individual is a child age six or younger.
b. The individual is disabled.
40. If a member is confined in a hospital and coverage is terminated, benefits will continue
until discharge from that facility.
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