2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 52
level of treatment, with no further medical improvements being made and exercise therapy that no longer
requires the supervision of medical professionals.
(10) Chemotherapy: Services and supplies related to chemotherapy. Precertification is required for
chemotherapy, see the Medical Management section for further details.
(11) Chiropractic Care/Spinal Manipulation: Skeletal adjustments, manipulation or other treatment in connection
with the correction by manual or mechanical means of structural imbalance or subluxation in the human body,
including x-rays. Eligible expenses will be payable as shown in the Medical Schedule of Benefits.
(12) Circumcision: Services and supplies related to circumcision. Circumcision performed while confined in a
Hospital following birth will be paid the same as Routine Newborn Care.
(13) Clinical Trial Programs: Clinical trial programs for the treatment of children’s cancer with respect to those
Dependent Children who:
(a)
Are covered under the Medical Plan;
(b)
Have been diagnosed with cancer prior to their 19th birthday;
(c)
Are enrolled in an approved clinical trial program for treatment of children’s cancer; and
(d)
Are not otherwise eligible for benefits, payments, or reimbursements from any other third party payors
or other similar sources.
(14) Cosmetic Procedures/Reconstructive Surgery: Cosmetic procedures or Reconstructive Surgery will be
considered eligible only under the following circumstances:
(a)
For the correction of a Congenital Anomaly for a Dependent Child.
(b)
Any other Medically Necessary Surgery related to an Illness or Injury.
(c)
Charges for reconstructive breast Surgery following a mastectomy will be eligible as follows:
(i)
Reconstruction of the breast on which the mastectomy has been performed;
(ii)
Surgery and reconstruction of the other breast to produce symmetrical appearance; and
(iii) Coverage for prostheses and physical complications of all stages of mastectomy, including
lymphedemas.
The manner in which breast reconstruction is performed will be determined in consultation with the
attending Physician and the Covered Person.
(15) Dental Care: Dental services and x-rays rendered by Dentist or dental surgeon for:
(a)
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth.
(b)
Emergency repair due to Injury to sound natural teeth including the replacement of sound natural teeth.
(c)
Surgery needed to correct accidental Injuries to the jaws, cheeks, lips, tongue, floor and roof of the
mouth.
(d)
Excision of benign bony growths of the jaw and hard palate.
(e)
External incision and drainage of cellulitis.
(f)
Incision of sensory sinuses, salivary glands or ducts.
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