2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix G. Alternative BenefitsG. Alternative Benefits Package Covered ServicesPackage Covered ServicesAppendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationAutism spectrum disorder Limitation: Services are only available to members through age 22. NoBariatric surgeryBehavioral health professionalservicesCancer Clinical TrialsLimitation: One surgery covered per lifetime. Criteria may be applied thatconsiders previous attempts by the member to lose weight, BMI and healthstatus.These include evaluations, therapy, and tests by licensed practitioners.This is a course of treatment provided to a patient for thepurpose of prevention of reoccurrence, early detection or treatment of cancerthat is being provided in New Mexico.YesNoNoCardiac rehabilitation Limitation: 36 hours per cardiac event NoChemotherapyChemotherapy is the use of chemical agents in the treatment or control ofdisease.NoDental services See Page 6-16. Yes, for select servicesand dental proceduresDiabetes treatment, includingdiabetic shoes and suppliesThis covers office visits, diabetes education and diabetic supplies includingdiabetic shoes, Insulin and diabetic oral agents for controlling blood sugar.Diabetic supplies used on an inpatient basis, applied as part of treatment in apractitioner’s office, outpatient hospital, residential facility, or a home healthservice, are covered when separate payment is allowed in these settings.Yes, for select servicesDiagnostic imaging andtherapeutic radiology servicesDialysis servicesDurable Medical Equipment (DME)and suppliesElectroconvulsive therapyCovered services include medically necessary imaging exams and radiologyservices ordered by doctors or other licensed providers. Some examples ofthese services are X-ray, ultrasound, magnetic resonance imaging (MRI),and computerized tomography (CT) scans.Medicaid covers medically necessary dialysis services and supplies furnishedto members receiving dialysis at home as well as services received from acontracted provider.This is equipment that is medically necessary for treatment of an illness oraccidental injury. It might also be needed to prevent further deterioration.DME is designed for repeated use. It includes items like oxygen equipmentand supplies necessary to use equipment wheelchairs, crutches and items toassist with treatment such as casts and splints that are applied by thehealthcare practitioner.ECT is a medical treatment for severe mental illness in which a small,carefully controlled amount of electricity is introduced into the brain, and isused to treat a variety of psychiatric disorders, including severe depression.Yes, for select servicesNoSome services mayrequire priorauthorizationYesEmergency services See Page 9-10. NoG-12014 Practitioner and Provider Manual - Ver. 3