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Diagnostic Services - X-rays and Laboratory Services Medically necessary diagnostic services, such as x-rays and laboratory examinations, are covered. For diagnostic services during routine examinations, see Wellness/Preventive Coverage. Refer to the Medical Management and Utilization Review section for certification requirements for specified outpatient diagnostic tests.

Outpatient diagnostic tests requiring certification:

CAT Scan


MRI Scan

UGI Endoscopy/EGD

Durable Medical Equipment Durable medical equipment (DME) must be prescribed by the attending physician and determined by Blue Cross & Blue Shield to be medically necessary for treatment of the illness or injury or to prevent the participant's further deterioration. Prior approval by Blue Cross & Blue Shield is recommended. DME is an item that must be (1) made to withstand repeated use; (2) primarily used to serve a medical purpose rather than for comfort or convenience; (3) generally not useful to a person in the absence of illness, injury, or disease; and (4) appropriate for use in the participant’s home.

Benefits for DME are based on the allowable charge for basic equipment. Benefits for any deluxe item will be limited to the allowable charge for the basic version of the item. If special features are medically necessary to maintain or promote patient mobility or function, Blue Cross & Blue Shield may approve those features. DME may be rented or purchased, based on Blue Cross & Blue Shield’s determination. Rental fees cannot exceed the cost of buying the item. A DME claim must include a letter explaining medical necessity from the physician.

Emergency Room Services Benefits are provided for treatment in a hospital emergency room. A $50 emergency room co- payment per visit will apply after the first emergency room visit in any calendar year. The emergency room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum.

Home Infusion Therapy Benefits are provided for home infusion therapy services approved by Intracorp for treatment in the patient’s home. Intracorp must certify services as medically necessary prior to beginning the therapy.

Covered expenses for Home Infusion Therapy are limited to the following:

  • Prescription drugs

  • Intravenous solutions

  • Durable medical equipment

  • Pharmacy compounding and dispensing services

  • Fees associated with drawing blood for the purpose of monitoring response to therapy

  • Therapist services

  • Ancillary medical supplies

  • Nursing visits – including initiation of home infusion therapy, intravenous restarts, and emergency care when medically necessary to provide home infusion therapy


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