2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 60
(51) Second Surgical Opinion: Voluntary second surgical opinions for elective, non-emergency Surgery when
recommended for a Covered Person.
Benefits for the second opinion will be payable only if the opinion is given by a specialist who: (a) is certified
in the field related to the proposed Surgery; and (b) is not affiliated in any way with the Physician
recommending the Surgery.
If the second opinion conflicts with the first opinion, the Covered Person may obtain a third opinion, although
this is not required.
(52) Sleep Disorders: Sleep disorder treatment that is Medically Necessary.
(53) Smoking Cessation: Smoking cessation programs and office visits will be payable as shown in the Medical
Schedule of Benefits. Smoking deterrents will be payable as shown in the Prescription Drug Card Program.
(54) Speech Therapy: Restorative or rehabilitative speech therapy under the recommendation of Physician and
necessary because of loss or impairment due to an Illness, or Surgery or therapy to correct a Congenital
Anomaly other than a learning disorder. Speech Therapy for developmental delay will not be considered
eligible. Outpatient Speech Therapy will be payable as shown in the Medical Schedule of Benefits.
(55) Temporomandibular Joint Dysfunction (TMJ): Surgical and non-surgical treatment of Temporomandibular
Joint Dysfunction (TMJ).
The treatment of jaw joint disorders (TMJ) includes conditions of structures linking the jawbone and skull and
complex muscles, nerves and other tissues related to the temporomandibular joint.
(56) Therapeutic Shoes or Inserts: Services and supplies will be covered as Durable Medical Equipment for
members who are diabetic and have severe diabetic foot disease. Covered benefit includes purchase and
fitting of either one pair of custom-molded shoes and inserts or one pair of extra-depth shoes each Calendar
Year. This benefit will also cover 2 additional pairs of inserts each Calendar Year for custom-molded shoes
and 3 pairs of inserts each Calendar Year for extra-depth shoes.
(57) Transplants (other than those received through the Aetna IOE Program): Services and supplies in
connection with Medically Necessary non-Experimental and/or non-Investigational transplant procedures,
subject to the following conditions:
Case Management is REQUIRED for transplant related claims when using the Aetna Network.
(a)
A concurring opinion must be obtained prior to undergoing any transplant procedure. This mandatory
opinion must concur with the attending Physician's findings regarding the Medical Necessity of such
procedure. The Physician rendering this concurring opinion must be qualified to render such a service
either through experience, specialist training, education, or such similar criteria, and must not be
affiliated in any way with the Physician who will be performing the actual Surgery.
(b)
If the donor is covered under this Medical Plan and the recipient is not, then the Medical Plan will cover
donor organ or tissue charges for (i) evaluating the organ or tissue; (ii) removing the organ or tissue
from the donor. No transportation charges will be considered. This Medical Plan will always pay
secondary to any other coverage. If the donor is not covered under this Medical Plan, reference
provision (d). If the recipient is covered under this Medical Plan, eligible medical expenses Incurred by
the recipient will be considered eligible.
(c)
If both the donor and the recipient are covered under this Medical Plan, eligible medical expenses
Incurred by each person will be treated separately for each person.
The Usual and Customary fee of securing an organ from the designated live donor, a cadaver or tissue
bank, including the surgeon's fees, anesthesiology, radiology and pathology fees for the removal of the
organ, and a Hospital's charge for storage or transportation of the organ will be considered eligible.
(d)
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