58 Benefits are limited to certain oral surgeries including: • Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; • Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or lower jaw and is Medically Necessary to attain functional capacity of the affected part. • Oral / surgical correction of accidental injuries as indicated in the “Dental Services (All Members/All Ages)” section. • Treatment of non-dental lesions, such as removal of tumors and biopsies. • Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. • Removal of impacted wisdom teeth. Reconstructive Surgery Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. Note: This section does not apply to orthognathic surgery. See the “Oral Surgery” section above for that benefit. Mastectomy Notice A Member who is getting benefits for a mastectomy or for follow-up care for a mastectomy and who chooses breast reconstruction, will also get coverage for: • Reconstruction of the breast on which the mastectomy has been performed; • Surgery and reconstruction of the other breast to give a symmetrical appearance; and • Prostheses and treatment of physical problems of all stages of mastectomy, including lymphedemas. Members will have to pay the same Deductible, Coinsurance, and/or Copayments that normally apply to surgeries in this Plan. Temporomandibular Joint (TMJ) and Craniomandibular Joint Services Benefits are available to treat temporomandibular and craniomandibular disorders. The temporomandibular joint connects the lower jaw to the temporal bone at the side of the head and the craniomandibular joint involves the head and neck muscles. Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures). Therapy Services Physical Medicine Therapy Services Your Plan includes coverage for the therapy services described below. To be a Covered Service, the therapy must improve your level of function within a reasonable period of time. Covered Services include: • Physical therapy – The treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg. It includes hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices.