Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...
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investig<strong>at</strong>ive under the above criteria may include<br />
one or more items from the following list, which is<br />
not all inclusive:<br />
° Published authorit<strong>at</strong>ive, peer-reviewed medical or<br />
scientifc liter<strong>at</strong>ure, or the absence thereof�<br />
° Evalu<strong>at</strong>ions of n<strong>at</strong>ional medical associ<strong>at</strong>ions,<br />
consensus panels, and other technology<br />
evalu<strong>at</strong>ion bodies�<br />
° Documents issued by or fled with the FDA or<br />
other federal, st<strong>at</strong>e, or local agency with the<br />
authority to approve, regul<strong>at</strong>e, or investig<strong>at</strong>e<br />
the use of the drug, biologic device, diagnostic<br />
product, equipment, procedure, tre<strong>at</strong>ment, service,<br />
or supply�<br />
° Documents of an Institutional Review Board (IRB)<br />
or other similar body performing substantially the<br />
same function�<br />
° Consent document(s) or the written protocol(s)<br />
used by the tre<strong>at</strong>ing physicians, other medical<br />
professionals, or facilities, or by other tre<strong>at</strong>ing<br />
physicians, other medical professionals, or<br />
facilities studying substantially the same drug,<br />
biologic device, diagnostic product, equipment,<br />
procedure, tre<strong>at</strong>ment, service, or supply�<br />
° Medical records�<br />
° The opinions of consulting providers and other<br />
experts in the feld�<br />
• Charges the provider is required to write of under<br />
another plan, when the other plan is primary payer<br />
over the Wells Fargo plan�<br />
• Charges the particip<strong>at</strong>ing provider is required<br />
to write of�<br />
• Charges for physician services for weak, strained,<br />
f<strong>at</strong>, unstable, or imbalanced feet; met<strong>at</strong>arsalgia or<br />
bunions (except open cutting oper<strong>at</strong>ions); or corns,<br />
calluses, or toenails (except removing nail roots and<br />
care in the tre<strong>at</strong>ment of metabolic or peripheralvascular<br />
disease)�<br />
• Charges for physician services for or x-ray<br />
examin<strong>at</strong>ions of mouth conditions due to periodontal<br />
or periapical disease or any condition involving teeth,<br />
surrounding tissue or structure, the alveolar process,<br />
or the gingival tissue, except for tre<strong>at</strong>ment or removal<br />
of malignant tumors; this exclusion includes root<br />
canal tre<strong>at</strong>ment�<br />
• Charges for rehabilit<strong>at</strong>ion services th<strong>at</strong> would<br />
not result in measurable progress rel<strong>at</strong>ive to<br />
established goals�<br />
• Charges th<strong>at</strong> are eligible, paid, or payable under<br />
any medical payment, personal injury protection,<br />
automobile, or other coverage (e�g�, homeowners<br />
insurance, bo<strong>at</strong> owners insurance, liability insurance,<br />
etc�) th<strong>at</strong> is payable without regard to fault, including<br />
charges for services th<strong>at</strong> are applied toward any<br />
deductible, copay, or coinsurance requirement of<br />
such a policy�<br />
• Communic<strong>at</strong>ion devices, except when exclusively<br />
used for the communic<strong>at</strong>ion of daily medical needs<br />
and without such communic<strong>at</strong>ion the p<strong>at</strong>ient’s<br />
medical condition would deterior<strong>at</strong>e�<br />
• Dentures, regardless of the cause or condition,<br />
and any associ<strong>at</strong>ed services or charges, including<br />
bone grafts�<br />
• Dental implants and any associ<strong>at</strong>ed services<br />
or charges�<br />
• Fees, dues, nutritional supplements, food, vitamins,<br />
and exercise therapy for or rel<strong>at</strong>ed to weight<br />
loss programs�<br />
• Health services provided in a foreign country, unless<br />
required as emergency health services�<br />
• Interest or l<strong>at</strong>e fees charged due to untimely payment<br />
for services�<br />
• Internet or similar network communic<strong>at</strong>ions for the<br />
purpose of scheduling medical appointments, reflling<br />
or renewing existing prescription medic<strong>at</strong>ions,<br />
reporting normal medical test results, providing<br />
educ<strong>at</strong>ion m<strong>at</strong>erials, upd<strong>at</strong>ing p<strong>at</strong>ient inform<strong>at</strong>ion, and<br />
requesting a referral, and services th<strong>at</strong> would similarly<br />
not be charged for an on-site medical ofce visit�<br />
• Inp<strong>at</strong>ient hospital room and board expenses<br />
th<strong>at</strong> exceed the semipriv<strong>at</strong>e room r<strong>at</strong>e, unless a<br />
priv<strong>at</strong>e room is approved by <strong>Anthem</strong> BCBS as<br />
medically necessary�<br />
• Modifc<strong>at</strong>ions to home, vehicle, or the workplace,<br />
including vehicle lifts and ramps�<br />
• Nonemergency care received outside the<br />
United St<strong>at</strong>es�<br />
• Nursing services to administer home infusion therapy<br />
when the p<strong>at</strong>ient or caregiver can be successfully<br />
trained to administer therapy; services th<strong>at</strong> do not<br />
involve direct p<strong>at</strong>ient contact, such as delivery<br />
charges and recordkeeping�<br />
• Personal comfort items, such as telephone, television,<br />
barber and beauty supplies, and guest services�<br />
<strong>Anthem</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> <strong>Shield</strong> <strong>PPO</strong> <strong>Plan</strong> 39