prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 80% After the plan deductible is met, your plan pays 60% Unlimited maximum per Contract Year Includes cranial banding, cranial orthoses and other similar devices based on medical necessity Routine Foot Disorders Not Covered Not Covered

Prosthetic appliances (including external breast prostheses, wigs) 80% 60% 80% 60% Breast pumps and supplies (electronic breast pump limited to one per pregnancy) … 2. Prosthetic devices and corrective appliances/orthotics must meet all of the following criteria: a. The item meets the definition of prosthetic or corrective appliances/orthotics (see Definitions). b. The item is furnished on a physician's order. • See the Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Orthotics Page updated: August 2020 This section lists the HCPCS codes and maximum allowances for orthotic appliances.

Your External prosthetic appliances, often referred to as prosthetic devices or prostheses, are devices used to replace the functions of missing body parts. A passive prosthesis is a type of device that must be moved manually, typically by the opposite arm. The standard prosthetic appliance for replacement of an upper Your CIGNA HealthCare PPO plan Page 1 PPO 2006-AZ External Prosthetic Appliances $200 EPA deductible per calendar year $1,000 maximum per calendar year# Internal prosthetic devices/surgical and medical appliances: Paid in full. External prosthetic devices/surgical and medical appliances: “Cigna®" is a – External prosthetic appliances – Biofeedback “CIGNA” and the “Tree of Life” logo are registered service marks of CIGNA Intellectual Property, Inc Cigna covers the surgical reimplantation of a medically necessary penile prosthetic device, following the medically necessary removal of a penile prosthesis, when benefit coverage is available. External Prosthetic Appliances (EPA) Your plan pays 100% $200 EPA annual deductible per Contract Year Unlimited maximum per Contract Year External prosthetic appliances meant to replace, in whole or in part, an arm, a leg or an eye: benefit levels will be the same as the benefit levels for primary care benefits. available, Cigna covers a microprocessor-controlled/computer-controlled lower limb prosthetic knee (HCPCS code L5856, L5857, L5858) device, including additions/components that are required for the effective use of the device, as medically necessary for an above-the-knee amputee when ALL of the External Prosthetic Appliances (EPA) Unlimited maximum per Contract Year Your plan pays 100% Routine Foot Disorders Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary. Acupuncture 40 days maximum per Contract Year $15 copay Hearing Aid $500 maximum per 36 months Proclaim - 8479929 - V 15 4 of 13 ©Cigna 2019 Benefit In-Network External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 80% Unlimited maximum per Calendar Year Routine Foot Disorders Not Covered Cigna covers a custom-fabricated AFO or KAFO (HCPCS code L1900, L1904, L1907, L1920, L1940– L1950, L1960–L1970, L1980–L2034, L2036–L2108 and L2126–L2128, L4631) in an AMBULATORY individual who meets the above medical necessity criteria for an AFO or KAFO and ANY ONE of the

The most important factor in choosing an external penile prosthetic is how well it fits into your sex life. This requires not only a genuine acknowledgment of your own sexual desires (and limitations) but those of your partner as well. If using the device makes you or your partner embarrassed or uncomfortable, it is unlikely to work.

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2019-01-01

The item meets the definition of prosthetic or corrective appliances/orthotics (see Definitions). b. The item is furnished on a physician's order. • See the Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics External Prosthetic Appliances No charge Family Planning Services Office Visits (Test, Counseling) Office Visit - $15 Copay Surgical Sterilization Procedure (Women) Surgical Sterilization Procedure (Men) Inpatient Hospital – No charge Outpatient Facility – No charge Inpatient Hospital - $100 Copay per admission prosthetic utilization beyond simple locomotion.

Your company value you as their employee so your health and well-being is as important to them as it is to you.With a Cigna dental plan they have given you the opportunity to get the protection and care your teeth deserve. appliance [ah-pli´ans] any of various devices used in dentistry to provide a functional or therapeutic effect, such as a prosthesis, an obturator, or an orthodontic appliance. fixed appliance an appliance that is attached to the teeth by cement or an adhesive material. orthodontic appliance a device, either fixed to the teeth or removable, that applies Agreement for the applicable medical equipment, medical supplies, and prosthetic devices benefits/coverage. Coding: A4280 Adhesive skin support attachment for use with external breast prosthesis, each (medical supply) L8000 Breast prosthesis, mastectomy bra (prosthesis) 2019-01-01 prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels.
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Deductible, then 20% to the Out of Pocket Maximum DURABLE MEDICAL EQUIPMENT Deductible, then 20% to the Out of Pocket Maximum EXTERNAL PROSTHETIC APPLIANCES Deductible, then 20% to the Out of Pocket Maximum OTHER BENEFITS ORAL SURGERY (accidents only) REMOVAL OF BONEY IMPACTED WISDOM TEETH Cigna care management helps you access the right care, at the right time, in the right setting. With precertification, you find out in advance if a service is covered, which can help you lower costs and avoid unnecessary procedures. › External prosthetic appliances Proclaim - 8458148 - V 15 5 of 14 ©Cigna 2019 Benefit In-Network Out-of-Network Breast Feeding Equipment and Supplies Limited to the rental of one breast pump per birth as ordered or prescribed by a physician Includes related supplies Your plan pays 100% After the plan deductible is met, your plan pays 70% External Prosthetic Appliances (EPA) Cigna care management helps you access the right care, at the right time, in the right setting. With precertification, – External prosthetic appliances – Speech therapy – Cosmetic or reconstructive procedures – Infertility treatment – Sleep management – Transplants External prosthetic devices/surgical and medical appliances Silver Health Gold Health Platinum Health; ฿65,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) Specialists' consultation fees Silver Health Gold Health Platinum Health; Paid in full. Paid in full.

Hospital Grade Breast Pumps. Outpatient Chemotherapy treatment Facility Charge. Myoelectric upper limb prosthetic components may be considered medically necessary when the following conditions are met: • The patient has an amputation or missing limb at the wrist or above (forearm, elbow, etc.); AND • Standard body-powered prosthetic devices cannot be used or are insufficient to meet the i) surgical appliance used by the physician during surgery, except all external prosthesis, special braces, equipment or appliances; and j) Medically Necessary western medicine services, medical disposals andconsumable, excluding items being covered under the other benefits of the Hospitalization and Surgical Benefits Fully covered 13. Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Prosthetics Page updated: September 2020 This section lists the HCPCS codes and maximum allowances for prosthetic appliances.
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With a Cigna dental plan they have given you the opportunity to get the protection and care your teeth deserve. Cigna's Level 3 Plan helps make a contribution towards mid-cost private dental charges. All Cigna plans can also be used at an NHS dentist. There is no need to be dentally fit before joining and because the

External Prosthetic Appliances. Calendar Year Maximum: Unlimited. Plan deductible, then 75% . Nutritional Evaluation. Health and Life Insurance Company (CIGNA) provides claim administration services only to the Coverage for replacement of external prosthetic appliances .