55 • Coverage is available only for use of a laparoscopically implanted magnetic esophageal ring where it is medically appropriate as outlined above. Covered and excluded procedures as well as clinical guidelines are subject to change without notice, as appropriate, in accordance with advances in treatment and changes in industry standards as determined by the Plan or the Claims Administrator. Note: Prior authorization review and approval is required. Please ask your physician to contact Quantum Health well in advance of any proposed procedure to implant or remove a laparoscopically implanted magnetic esophageal ring. Mental Health Services The Facility, Practitioner, and Medical Support Charges incurred for the treatment of mental health conditions are covered medical charges under the terms of the Plan, provided the charges meet Mental Health Services definition. No other charges outside this definition incurred for treatment of mental health conditions are covered medical charges under the terms of the Plan. Benefits for Mental Health Services will be eligible for payment only if the treatment is provided by a Hospital or a Mental Health Residential Treatment Center, or by a physician or a psychologist holding a Master or Doctorate in Psychology, or another similarly degreed practitioner legally licensed to provide Mental Health Services or practice psychotherapy by the state in which he or she practices. Coverage is provided for both inpatient and outpatient Mental Health Services, including, but not limited to, treatment of conditions such as anxiety or depression which interfere with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic mental health conditions (crisis intervention and relapse prevention), and outpatient testing and assessment. Covered services also may include inpatient care at a Mental Health Residential Treatment Center, Partial Hospitalization, and Intensive Outpatient Therapy programs. Except for Applied Behavioral Analysis (ABA) therapy for the treatment of autism spectrum disorder, the Plan does not cover diagnoses such as learning, behavioral and developmental disorders under this benefit or under any other benefit. Neither does the Plan cover therapies such as art, music, drama, physical, speech, recreational, occupational, and adjunctive under this benefit or any other benefit. Nutritional Evaluation Charges for nutritional evaluation and counseling are covered medical charges under the terms of the Plan when ordered by a physician, but only when diet is part of the medical management of a diagnosed and documented organic illness. Organ Transplant Charges in connection with Medically Necessary, non-experimental, human organ and tissue transplant, including services that include solid organ and bone marrow/stem cell procedures, are covered medical charges under the terms of the Plan as provided below: