Spinal Manipulation Services Sample Clauses
Spinal Manipulation Services. Benefits are provided for spinal manipulations for the detection and correction by manual or mechanical means of structural imbalance or subluxation resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column.
Spinal Manipulation Services. Benefits are provided for spinal manipulations for the detection and correction by manual or mechanical means of structural imbalance or subluxation resulting from or related to distortion, misalignment, or subluxation of or in the vertebral column. The following are excluded from your coverage:
1. Which are not Medically Necessary as determined by Keystone Health Plan Central’s Medical Director(s) or his/her designee(s);
2. Which are considered by Keystone Health Plan Central to be Investigational, except where otherwise required by law;
3. For any illness or injury which occurs in the course of employment if Benefits or compensation are available or required, in whole or in part, under a workers’ compensation policy and/or any federal, state or local government’s workers’ compensation law or occupational disease law, including but not limited to, the United States Longshoreman’s and Harbor Workers’ Compensation Act as amended from time to time. This exclusion applies whether or not the Member makes a claim for the Benefits or compensation under the applicable workers’ compensation policy/coverage and/or the applicable law;
4. For any illness or injury suffered after the Member’s Effective Date of Coverage which resulted from an act of war, whether declared or undeclared;
5. For services received by veterans and active military personnel at facilities operated by the Veteran’s Administration or by the Department of Defense, unless payment is required by law;
6. Which are received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group;
7. For the cost of Hospital, medical, or other Benefits resulting from accidental bodily injury arising out of a motor vehicle accident, to the extent such Benefits are payable under any medical expense payment provision (by whatever terminology used, including such Benefits mandated by law) of any motor vehicle insurance policy;
8. For items or services paid for by Medicare when Medicare is primary consistent with the Medicare Secondary Payer Laws. This exclusion shall not apply when the Contract Holder is obligated by law to offer the Member the Benefits of this Coverage as primary and the Member so elects this Coverage as primary;
9. For care of conditions that federal, state or local law requires to be treated in a public facility;
10. For court ordered services when not Medically Necessary and/or not a covered Benefit;
11....
Spinal Manipulation Services. Coverage shall be provided for Medically Necessary spinal manipulation, evaluation and treatment for the musculoskeletal conditions of the spine when provided by a licensed chiropractor, doctor of osteopathy (D.O.) or other eligible practitioner who is a Contracting Provider. Benefits will not be provided for spinal manipulation services other than for musculoskeletal conditions of the spine. Spinal Manipulation services are limited to Members who are twelve (12) years of age or older.
1. Prior authorization is not required for spinal manipulation services or for any other service provided by the same provider on the same day as these services.