Subject to the American Cancer Society guidelines, and medical necessity as determined by the [Member’s] Practitioner in consultation with the [Member] regarding methods to use, We will cover charges for: Annual gFOBT (guaiac-based fecal occult blood test) with high test sensitivity for cancer; Annual FIT (immunochemical-based fecal occult blood test) with high test sensitivity for cancer; Stool DNA (sDNA) test with high sensitivity for cancer flexible sigmoidoscopy, colonoscopy; contrast barium enema; Computed Tomography (CT) Colonography any combination of the services listed in items a – g above; or any updated colorectal screening examinations and laboratory tests recommended in the American Cancer Society guidelines. We will cover the above methods at the frequency recommended by the most recent published guidelines of the American Cancer Society and as determined to be medically necessary by the [Member’s] practitioner in consultation with the [Member.] High risk for colorectal cancer means a [Member] has: A family history of: familial adenomatous polyposis, heriditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; Chronic inflammatory bowel disease; or A background, ethnicity or lifestyle that the practitioner believes puts the person at elevated risk for colorectal cancer. Please note that colorectal cancer screening is included under the Preventive Care provision. Private Duty Nursing Care We only cover charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section. Any other charges for private duty nursing care are not covered. Therapy Services Therapy Services mean the following services or supplies, ordered by a Practitioner and used to treat, or promote recovery from, an Injury or Illness: Subject to the stated limits, We cover the Therapy Services listed below. We cover other types of Therapy Services provided they are performed by a licensed Provider, are Medically Necessary and Appropriate and are not Experimental or Investigational.
Subject to the American Cancer Society guidelines, and medical necessity as determined by the [Member’s] Practitioner in consultation with the [Member] regarding methods to use, We will cover charges for: Annual gFOBT (guaiac-based fecal occult blood test) with high test sensitivity for cancer; Annual FIT (immunochemical-based fecal occult blood test) with high test sensitivity for cancer; Stool DNA (sDNA) test with high sensitivity for cancer flexible sigmoidoscopy, colonoscopy; contrast barium enema; Computed Tomography (CT) Colonography any combination of the services listed in items a – g above; or any updated colorectal screening examinations and laboratory tests recommended in the American Cancer Society guidelines. We will cover the above methods at the frequency recommended by the most recent published guidelines of the American Cancer Society and as determined to be medically necessary by the [Member’s] practitioner in consultation with the [Member.] High risk for colorectal cancer means a [Member] has: A family history of: familial adenomatous polyposis, heriditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; Chronic inflammatory bowel disease; or A background, ethnicity or lifestyle that the practitioner believes puts the person at elevated risk for colorectal cancer. Please note that colorectal cancer screening is included under the Preventive Care provision. Private Duty Nursing Care We only cover charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section. Any other charges for private duty nursing care are not covered. Therapy Services Therapy Services mean the following services or supplies, ordered by a Practitioner and used to treat, or promote recovery from, an Injury or Illness: Subject to the stated limits, We cover the Therapy Services listed below. We cover other types of Therapy Services provided they are performed by a licensed Provider, are Medically Necessary and Appropriate and are not Experimental or Investigational.
HMO%20POS%20EOC%202018%20A.docx