2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix G. Alternative Benefits Package Covered ServicesCovered Service Description Prior AuthorizationPhysical therapy servicesThese services promote gross and fine motor skills, help with independentfunctioning and prevent progressive disabilities.NoLimitation: Short-term therapy only for a two-month period from the initialdate of treatment.Physician visitsThese are provider services required by members to maintain good health.They include but are not limited to periodic exams and office visits providedby licensed providers.NoPodiatry servicesThese are only medically necessary podiatric services given by providers, asrequired by the member’s condition.Covered services includeRoutine foot care when there is evidence of a systemic condition,circulatory distress, or areas of diminished sensation in the feetdemonstrated through physical or clinical examRoutine foot care, non-surgical and surgical correction of asubluxated foot structureTreatment of warts on the feetTreatment of asymptomatic nails with a fungal infection may becoveredOrthopedic shoes and other supportive devices only when the shoe is anintegral part of a leg brace or therapeutic shoes furnished to diabetics.NoPregnancy terminationproceduresSee Page 18-8.Preventive services See Page 6-23. NoNoProsthetics and orthoticsPulmonary rehabilitationProsthetics and orthotics supplied by providers are covered only when certainrequirements or conditions are satisfied. Prosthetic devices are replacementsor substitutes for a body part or organ, such as an artificial limb or eye.Orthotic devices support or brace the body, such as trusses, compressioncustom-made stockings, and braces.Limitation: Foot orthotic, including shoe and arch supports, are only coveredwhen an integral part of a leg brace or diabetic shoes.Limitation: 36 hours per year.YesNoReproductive health services See Pages F-11 and F-12. NoSkilled nursingSkilled nursing is generally provided only through a home health agency.However, it can also be provided through private duty nursing.YesSmoking cessation/ tobaccoservicesThese include diagnostic services, tobacco/smoking cessation counselingand pharmacotherapy. Group counseling, including classes or a telephoneQuit Line, are covered when offered by an in-network provider. Someorganizations, such as the American Cancer Society and the Tobacco UsePrevention and Control (TUPAC), offer group counseling services at nocharge.NoG-42014 Practitioner and Provider Manual - Ver. 3