CALIFORNIA - Pacificare Health Systems

PART A
22
Your Medical Benefits
Network Facility. Listing of the Member at a
second Preferred Transplant Network Center is
excluded, unless the Regional Organ Procurement
Agencies are different for the two facilities and the
Member is accepted for listing by both facilities.
In these cases, organ transplant listing is limited
to two National Preferred Transplant Network
facilities. If the Member is dual listed, his or her
coverage is limited to the actual transplant at the
second facility. The Member will be responsible
for any duplicated diagnostic costs incurred at the
second facility. Covered Services for living donors
are limited to Medically Necessary clinical services
once a donor is identified. Transportation and
other nonclinical expenses of the living donor are
excluded and are the responsibility of the Member
who is the recipient of the transplant. (See the
definition for “National Preferred Transplant
Network.”)
16. Reconstructive Surgery – Reconstructive surgery
is covered to correct or repair abnormal structures
of the body caused by congenital defects,
developmental abnormalities, trauma, infection,
tumors or disease. The purpose of reconstructive
surgery is to correct abnormal structures of the
body to improve function or create a normal
appearance to the extent possible. Reconstructive
procedures require Preauthorization by the
Member’s Participating Medical Group or
PacifiCare in accordance with standards of
care as practiced by Physicians specializing in
reconstructive surgery. PacifiCare covers certain
transgender surgery and services related to
the surgery to change a Member’s physical
characteristics to those of the opposite gender.
Inpatient and Outpatient Services for transgender
surgery and services related to the surgery require
prior authorization by PacifiCare and are subject
to a combined Inpatient and Outpatient lifetime
benefit maximum of $75,000 for each Member
17. Skilled Nursing/Subacute and Transitional
Care – Medically Necessary Skilled Nursing Care
and Skilled Rehabilitation Care are covered.
The Member’s Participating Medical Group or
PacifiCare will determine where the Skilled
Nursing Care and Skilled Rehabilitation Care will
be provided.
Skilled Nursing Facility room and board
charges are covered up to 100 consecutive
days per admission. Days spent out of a Skilled
Nursing Facility when transferred to an acute
Hospital setting are not counted toward the
100-consecutive-day room and board limitation
when the Member is transferred back to a
Skilled Nursing Facility. Such days spent in an
acute Hospital setting also do not count toward
renewing the 100-consecutive-day benefit. In
order to renew the room and board coverage
in a Skilled Nursing Facility, the Member must
either be out of all Skilled Nursing Facilities for
60 consecutive days, or if the Member remains in
a Skilled Nursing Facility, then the Member must
not have received Skilled Nursing Care or Skilled
Rehabilitation Care for 60 consecutive days.
18. Voluntary Termination of Pregnancy – Refer
to the Schedule of Benefits for the terms of any
coverage, if any.
II. Outpatient Benefits*
The following benefits are available on an outpatient
basis and must be provided by the Member’s Primary
Care Physician or authorized by the Member’s
Participating Medical Group or PacifiCare. All services
must be Medically Necessary as defined in this
Combined Evidence of Coverage and Disclosure Form.
1. Alcohol, Drug or Other Substance Abuse
Detoxification – Detoxification is the medical
treatment of withdrawal from alcohol, drug or
other substance addiction. Medically Necessary
detoxification is covered. Methadone treatment
for detoxification is not covered. In most cases
of alcohol, drug or other substance abuse or
toxicity, outpatient treatment is appropriate
unless another medical condition requires close
inpatient monitoring. Rehabilitation for substance
abuse or addiction is not covered.
2. Allergy Testing – Allergy serum, as well as
needles, syringes, and other supplies for the
administration of the serum, are covered for the
* The benefits described in Section Five will not be Covered Services unless they are determined to be Medically
Necessary by Member’s Participating Medical Group or PacifiCare and are provided by Member’s Primary Care
Physician or authorized by Member’s Participating Medical Group or PacifiCare.