40. Mental Health Treatment. (Refer to the Mental Health Benefits section of this SPD.) 41. Morbid Obesity Treatment includes only the following treatments if those treatments are determined to be Medically Necessary and be appropriate for an individual's Morbid Obesity condition. Refer to the Glossary of Terms for a definition of Morbid Obesity. • Charges for diagnostic services. • Nutritional counseling by registered dieticians or other Qualified Providers. This Plan does not cover diet supplements, exercise equipment or any other items listed in the General Exclusions section of this SPD. 42. Nursery and Newborn Expenses, Including Circumcision, are covered for the following Children of the covered Employee or covered spouse: natural (biological) Children and newborn Children who are adopted or Placed for Adoption at the time of birth. 43. Nutritional Counseling if Medically Necessary. 44. Nutritional Supplements, Enteral Feedings, Vitamins, and Electrolytes that are prescribed by a Physician and administered through a tube, provided they are the sole source of nutrition or are part of a chemotherapy regimen. This includes supplies related to enteral feedings (for example, feeding tubes, pumps, and other materials used to administer enteral feedings), provided the feedings are prescribed by a Physician and are the sole source of nutrition or are part of a chemotherapy regimen. 45. Occupational Therapy. (See Therapy Services below.) 46. Oral Surgery for Accident only includes: • Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof, and floor of the mouth when such conditions require pathological examinations. • Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof, and floor of the mouth. • Reduction of fractures and dislocations of the jaw. • External incision and drainage of cellulitis. • Incision of accessory sinuses, salivary glands, or ducts. • Excision of exostosis of jaws and hard palate. 47. Orthognathic, Prognathic, and Maxillofacial Surgery when Medically Necessary. 48. Orthotic Appliances, Devices, and Casts, including the exam for required Prescription and fitting, when prescribed to aid in healing, provide support to an extremity, or limit motion to the musculoskeletal system after Injury. These devices can be used for acute Injury or to prevent Injury. Orthotic appliances and devices include custom molded shoe orthotics, supports, trusses, elastic compression stockings, and braces. 49. Oxygen and Its Administration. 50. Pharmacological Medical Case Management (medication management and lab charges). 51. Physical Therapy. (See Therapy Services below.) 52. Physician Services for covered benefits. 53. Pre-Admission Testing if necessary and consistent with the diagnosis and treatment of the condition for which the Covered Person is being admitted to the Hospital. -63- 7670-00-413597