56 Transplant services include the covered recipient’s medical, surgical and Hospital services; inpatient immunosuppressive medications; and costs for organ or bone marrow/stem cell procurement. Transplant services are covered only if they are required to perform any of the following human to human organ or tissue transplants; allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or intestinal which includes small bowel, liver or multivisceral. All covered transplant services that are provided by non-participating providers will be payable at the out-of-network level under the terms of the Plan. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal and organ transportation. Charges for transportation and hospitalization of a live donor are covered only if both the donor and the recipient are covered Plan participants. Donor compatibility testing undertaken before procurement, and costs related to the search for, and identification of, a bone marrow or stem cell donor for an allogeneic transplant are also covered, but only if both the potential donor and the recipient are covered Plan participants. Podiatry Care The charges for podiatry care that are covered medical charges include Medically Necessary services of a podiatrist acting within the scope of his or her license. For example, podiatry care includes charges for the diagnosis and treatment of chronic foot pain; instability or imbalance of the feet; foot deformities; and toenail infections. Podiatry care also includes the charge for custom molded orthotics, but does not include the charge for shoes or prefabricated shoe inserts. The podiatry care benefit does not cover routine foot care such as paring and removal of corns and calluses or trimming of toenails. However, services associated with foot care for diabetes and peripheral vascular disease are covered medical charges when Medically Necessary under the terms of the Plan. Podiatry care is limited to 30-days maximum per calendar year, regardless of the service provider. Benefits for Medically Necessary surgery are not subject to the 30-days limitation but are payable on the same basis as benefits for any other covered surgery. Preventive and Wellness Services The Plan provides the following preventive and wellness services for all covered participants in keeping with prevailing medical standards, including frequency and age recommendations, as appropriate for the type of service. The requirement that benefits be paid only for charges that are Medically Necessary does not apply to these routine services. Preventive Services are required by the Affordable Care Act (ACA). If coverage is provided in- network, there is no cost sharing (for example, no deductibles, coinsurance, or copayments) for the following preventive services: • Services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations; • Services described in guidelines issued by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC); and
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