• Skin resurfacing • Testicular prosthesis • Urethroplasty (reconstruction of female urethra) • Urethroplasty (reconstruction of male urethra) • Vaginectomy (removal of vagina) • Vaginoplasty (creation of vagina) • Vulvectomy (removal of vulva) 27. Genetic Counseling based on Medical Necessity. 28. Genetic Testing when Medically Necessary (see below). Genetic testing MUST meet the following requirements: The test must not be considered Experimental, Investigational, or Unproven. The test must be performed by a CLIA-certified laboratory. The test result must directly impact or influence the disease treatment of the Covered Person Genetic testing must also meet at least one of the following: • The patient has current signs and/or symptoms (i.e., the test is being used for diagnostic purposes). • Conventional diagnostic procedures are inconclusive. • The patient has risk factors or a particular family history that indicates a genetic cause. • The patient meets defined criteria that place him or her at high genetic risk for the condition. 29. Hearing Services include: • Exams, tests, services, and supplies to diagnose and treat a medical condition. • Implantable hearing devices. 30. Home Health Care Services: (Refer to the Home Health Care Benefits section of this SPD.) 31. Hospice Care Services: Treatment given at a Hospice Care facility must be in place of a stay in a Hospital or Extended Care Facility, and may include: • Assessment, which includes an assessment of the medical and social needs of the Terminally Ill person and a description of the care required to meet those needs. • Inpatient Care in a facility when needed for pain control and other acute and chronic symptom management, psychological and dietary counseling, physical or occupational therapy, and part- time Home Health Care services. • Outpatient Care, which provides or arranges for other services related to the Terminal Illness, including the services of a Physician or Qualified physical or occupational therapist or nutrition counseling services provided by or under the supervision of a Qualified dietician. • Respite Care when part of an integrated Hospice program to provide temporary relief for 4 hours, per week to the family or other caregivers in the case of an Emergency or to provide temporary relief from the daily demands of caring for a terminally ill person. • Bereavement Counseling: services that are received by a Covered Person’s Close Relative when directly connected to the Covered Person’s death and the charges for which are bundled with other hospice charges. Counseling services must be provided by a Qualified social worker, Qualified pastoral counselor, Qualified psychologist, Qualified psychiatrist, or other Qualified Provider, if applicable. The services must be furnished within 12 months of death. The Covered Person must be Terminally Ill with an anticipated life expectancy of about six months. However, services are not limited to a maximum of six months if continued Hospice Care is deemed appropriate by the Physician, up to the maximum hospice benefits available under the Plan. -61- 7670-00-413597