CALIFORNIA - Pacificare Health Systems

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Preauthorized by PacifiCare. 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 “Preferred Transplant
Network.”)
Food and housing is not covered unless the
Preferred Transplant Network Center is located
more than 60 miles from the Member’s Primary
Residence, in which case food and housing
is limited to $125.00 a day to cover both the
Member and escort, if any (excludes liquor and
tobacco). Food and housing expenses are not
covered for any day a Member is not receiving
Medically Necessary transplant services.
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
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 is responsible for any
duplicated diagnostic costs incurred at the
second facility. (See the definition for “Regional
Organ Procurement Agency.”)
51. Pain Management – Pain management services
are covered for the treatment of chronic and
acute pain only when they are received from a
Participating Provider and authorized by PacifiCare
or its designee.
52. Phenylketonuria (PKU) Testing and Treatment
– Food products naturally low in protein are not
covered.
53. Physical or Psychological Examinations –
Physical or psychological examinations for court
hearings, travel, premarital, pre-adoption or other
nonpreventive health reasons are not covered.
54. Private Rooms and Comfort Items – Personal
or comfort items, and non-Medically Necessary
private rooms during inpatient hospitalization are
not covered.
55. Prosthetics and Corrective Appliances –
Replacement of lost prosthetics or corrective
Your Medical Benefits
appliances is not covered. Prosthetics that require
surgical connection to nerves, muscles or other
tissues (bionic) are not covered. Prosthetics
that have electric motors to enhance motion
(myoelectronic) are not covered. For a detailed
listing of covered durable medical equipment,
including prosthetics and corrective appliances,
please contact the PacifiCare Customer Service
department at 1-800-624-8822.
56. Pulmonary Rehabilitation Programs –
Pulmonary rehabilitation programs are covered
only when determined to be Medically Necessary
by a PacifiCare Medical Director or designee.
57. Reconstructive Surgery – Reconstructive
surgeries are not covered under the following
circumstances:
When there is another more appropriate
surgical procedure that has been offered to the
Member; or
When only a minimal improvement in the
Member’s appearance is expected to be
achieved.
Preauthorizations for proposed reconstructive
surgeries will be reviewed by Physicians
specializing in such reconstructive surgery who
are competent to evaluate the specific clinical
issues involved in the care requested.
58. Recreational, Lifestyle, Educational or
Hypnotic Therapy – Recreational, lifestyle,
educational or hypnotic therapy, and any related
diagnostic testing is not covered.
59. Rehabilitation Services and Therapy –
Rehabilitation services and therapy are either
limited or not covered, as follows:
Speech, occupational or physical therapy is not
covered when medical documentation does
not support the Medical Necessity because of
the Member’s inability to progress toward the
treatment plan goals or when a Member has
already met the treatment goals.
Speech therapy is limited to Medically
Necessary therapy to treat speech disorders
caused by a defined illness, disease or surgery
(for example, cleft palate repair).
Cognitive Rehabilitation Therapy is limited
Questions? Call the Customer Service Department at 1-800-624-8822. 39
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PART A