Noblesville Schools Medical Plan 53 Section 1: Covered Health Care Services • Discharge rehabilitation goals have previously been met. Surgery - Outpatient Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Benefits include certain scopic procedures. Examples of surgical scopic procedures include: • Arthroscopy. • Laparoscopy. • Bronchoscopy. • Hysteroscopy. Examples of surgical procedures performed in a Physician's office are mole removal, ear wax removal, and cast application. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Temporomandibular Joint (TMJ) Services Services for the evaluation and treatment of TMJ and associated muscles. Diagnosis: Exam, radiographs and applicable imaging studies and consultation. Non-surgical treatment including: • Clinical exams. • Oral appliances (orthotic splints). • Arthrocentesis. • Trigger-point injections. Benefits are provided for surgical treatment if the following criteria are met: • There is radiographic evidence of joint abnormality. • Non-surgical treatment has not resolved the symptoms. • Pain or dysfunction is moderate or severe. Benefits for surgical services include: • Arthrocentesis. • Arthroscopy. • Arthroplasty. • Arthrotomy. • Open or closed reduction of dislocations. Benefits for surgical services also include FDA-approved TMJ prosthetic replacements when all other treatment has failed.