CALIFORNIA - Pacificare Health Systems

PART A
36
Your Medical Benefits
expedited external, independent review of
PacifiCare’s coverage determination regarding
Experimental or Investigational therapies as
described in Section 9. Overseeing Your Health
Care Decisions, “Experimental or Investigational
Treatment Decisions.”
26. Eyewear and Corrective Refractive Procedures
– Corrective lenses and frames, contact lenses and
contact lens fitting and measurements are not
covered (except for initial post-cataract extraction
or corneal bandages and for the treatment of
keratoconus and aphakia). Surgical and laser
procedures to correct or improve refractive error
are not covered. Routine screenings for glaucoma
are limited to Members who meet the medical
criteria.
27. Family Planning – Family planning benefits,
other than those specifically listed in the Schedule
of Benefits that accompanies this document, are
not covered.
28. Follow-Up Care: Emergency Services or
Urgently Needed Services – Services following
discharge after receipt of Emergency Services
or Urgently Needed Services, including, but
not limited to, treatments, procedures, X-rays,
lab work, Physician visits, rehabilitation and
Skilled Nursing Care are not covered without
the Participating Medical Group’s or PacifiCare’s
authorization. The fact that the Member is outside
the Service Area and that it is inconvenient for the
Member to obtain the required services from the
Participating Medical Group will not entitle the
Member to coverage.
29. Foot Care – Except as Medically Necessary,
routine foot care, including, but not limited to,
removal or reduction of corns and calluses and
clipping of toenails, is not covered.
30. Foot Orthotics/Footwear – Specialized footwear,
including foot orthotics and custom-made or
standard orthopedic shoes, is not covered, except
for Members with diabetic foot disease or when
an orthopedic shoe is permanently attached to a
Medically Necessary orthopedic brace.
31. Genetic Testing and Counseling – Genetic
testing of non-Members is not covered. Genetic
testing solely to determine the gender of a fetus
is not covered. Genetic testing and counseling are
not covered when done for nonmedical reasons
or when a Member has no medical indication or
family history of a genetic abnormality. General
testing and counseling are not covered to screen
newborns, children or adolescents to determine
their carrier status for inheritable disorders
when there would be no immediate medical
benefit or when the test results would not be
used to initiate medical interventions during
childhood. Nonmedical reasons (e.g., courtordered
test, work-related tests, paternity tests).
Genetic testing and counseling are not covered
except when determined by PacifiCare’s Medical
Director or designee to be Medically Necessary
to treat the Member for an inheritable disease.
Refer to “Maternity Care Test and Procedures” in
the “Outpatient Benefits” section for coverage of
amniocentesis and chorionic villus sampling.
Refer to “Maternity Care, Tests, Procedures, and
Genetic Testing” in the “Outpatient Benefits”
section for coverage of amniocentesis and
chorionic villus sampling.
32. Government Services and Treatment – Any
services that the Member receives from a local,
state or federal governmental agency are not
covered, except when coverage under this Health
Plan is expressly required by federal or state law.
33. Hearing Aids and Hearing Devices – Hearing
aids and nonimplantable hearing devices are not
covered. Audiology services (other than screening
for hearing acuity) are not covered. Hearing aid
supplies are not covered. Implantable hearing
devices are not covered except for cochlear
devices for bilaterally, profoundly hearing
impaired individuals or for prelingual Members
who have not benefited from conventional
amplification (hearing aids).
34. Hospice Services – Hospice services are not
covered for:
* 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.