50 be demonstrated. Note: Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. • A thorough multidisciplinary evaluation within the previous 12-months that includes: − An evaluation by a bariatric surgeon who is recommending surgical treatment, including a description of the proposed procedure(s) and all associated current procedure codes; − A separate medical evaluation, from a physician other than the surgeon who is recommending surgery, that includes a medical clearance for bariatric surgery; − Unequivocal clearance for bariatric surgery by a mental health provider; − A nutritional evaluation by a physician or registered dietician. Note : The procedures set forth herein do not preclude nutritional counseling where the covered individual has a BMI of more than 30, as covered by the Preventive Services benefit. Coverage Information Charges for bariatric surgery are subject to all limitations as set forth in the Schedule of Benefits and the section on Covered Charge Limits. Coverage for these services is limited to in-network benefits for contracted Hospitals and facilities designated as Centers of Excellence for Bariatric Surgery, and their affiliated contracted providers. Any CareFirst contracted facility may be used when a center of excellence is not available. • There is no out-of-network coverage for bariatric surgery. • Coverage is available only for certain bariatric surgery procedures that Quantum Health determines are medically appropriate. Coverage is excluded for bariatric surgery procedures that are considered experimental, investigational, or unproven. Please contact a hospital or facility that is designated as a CareFirst Center of Excellence for Bariatric Surgery to determine whether the Plan covers a proposed bariatric surgery procedure. • Services required to establish Medical Necessity of bariatric surgery are not automatically included in this benefit. The Plan provides coverage for some required services (e.g., evaluation by a bariatric surgeon) but does not necessarily provide coverage for all required services (e.g., weight management programs). Each service must be considered independently for purposes of determining whether the service is covered under the terms of the Plan. Please examine the details set forth in this SPD and/or speak to a Quantum Health representative to determine which pre- surgical services are covered under the Plan. Covered and excluded bariatric surgery procedures and clinical guidelines are subject to change without notice, as appropriate, in accordance with advances in treatment and changes in industry standards as Quantum Health determines. Please ask your physician to contact Quantum Health well in advance of any proposed bariatric surgery. Chiropractic Care Charges for chiropractic services are covered medical charges provided that: (a) the services are Medically Necessary treatment of musculoskeletal disease or injury, and (b) the services are restorative in nature, designed to restore levels of function that had previously existed but that have been lost due