Clinical Trials ........................................................................................................................................... 43 Dental Services ....................................................................................................................................... 44 Preparing the Mouth for Medical Treatments ...................................................................................... 44 Treatment of Accidental Injury ............................................................................................................. 44 Anesthesia and Hospital Charges for Dental Care .............................................................................. 44 Diabetes Equipment, Education, and Supplies ....................................................................................... 45 Diagnostic Services ................................................................................................................................. 45 Diagnostic Laboratory and Pathology Services ................................................................................... 45 Diagnostic Imaging Services and Electronic Diagnostic Tests ............................................................ 45 Advanced Imaging Services ................................................................................................................ 45 Dialysis .................................................................................................................................................... 46 Durable Medical Equipment (DME), Medical Devices, and Supplies .................................................. 46 Orthotics ............................................................................................................................................... 46 Prosthetics ........................................................................................................................................... 46 Prosthetic Limbs & Orthotic Custom Fabricated Brace or Support ..................................................... 47 Medical and Surgical Supplies ............................................................................................................. 47 Blood and Blood Products ................................................................................................................... 48 Emergency Care Services ....................................................................................................................... 48 Emergency Services ............................................................................................................................ 48 Habilitative Services ................................................................................................................................ 49 Home Health Care Services .................................................................................................................... 49 Home Infusion Therapy ........................................................................................................................... 50 Hospice Care ........................................................................................................................................... 50 Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services, Cellular and Gene Therapy Services ................................................................................................................................................... 50 Prior Approval and Precertification ...................................................................................................... 51 Inpatient Services .................................................................................................................................... 52 Inpatient Hospital Care ........................................................................................................................ 52 Inpatient Professional Services ........................................................................................................... 53 Maternity and Reproductive Health Services .......................................................................................... 53 Maternity Services ............................................................................................................................... 53 Contraceptive Benefits ......................................................................................................................... 54 Sterilization Services ............................................................................................................................ 54 Infertility Services ................................................................................................................................. 54 Mental Health and Substance Use Disorder Services ............................................................................ 55 Occupational Therapy ............................................................................................................................. 55 Office and Home Visits ............................................................................................................................ 55 Orthotics .................................................................................................................................................. 56 Outpatient Facility Services ..................................................................................................................... 56 Physical Therapy ..................................................................................................................................... 56 Preventive Care ....................................................................................................................................... 56 Preventive Care for Chronic Conditions (per IRS guidelines) ................................................................. 58 Prosthetics ............................................................................................................................................... 58 Pulmonary Therapy ................................................................................................................................. 58 Radiation Therapy ................................................................................................................................... 58 Rehabilitation Services ............................................................................................................................ 58 Respiratory Therapy ................................................................................................................................ 58 Skilled Nursing Facility ............................................................................................................................ 59 Smoking Cessation .................................................................................................................................. 59 Speech Therapy ...................................................................................................................................... 59 Surgery .................................................................................................................................................... 59 Oral Surgery ......................................................................................................................................... 59 Reconstructive Surgery........................................................................................................................ 59 Temporomandibular Joint (TMJ) and Craniomandibular Joint Services ................................................. 60 Therapy Services ..................................................................................................................................... 60 Physical Medicine Therapy Services ................................................................................................... 60 9