 Compression garments for burns.  Diabetic foot care appliances and therapeutic shoes and inserts to prevent and treat diabetes-related complications.  External prostheses after a Medically Necessary mastectomy, including prostheses when Medically Necessary, and up to four brassieres required to hold a prosthesis every 12 months.  Fitting and adjustments.  Halo vests.  Lymphedema wraps and garments.  Maxillofacial prosthetic devices: coverage is limited to the least costly clinically appropriate treatment as determined by a Participating Provider. We cover maxillofacial prosthetic devices if they are necessary for restoration and management of head and facial structures that cannot be replaced with living tissue and are defective because of disease, trauma, or birth and developmental deformities when this restoration and management are performed for the purpose of: • Controlling or eliminating infection; • Controlling or eliminating pain; or • Restoring facial configuration or functions such as speech, swallowing, or chewing, but not including cosmetic procedures rendered to improve the normal range of conditions.  Ocular prosthesis.  Prosthetic devices for treatment of temporomandibular joint (TMJ) conditions.  Prosthetic devices required to replace all or part of an organ or extremity, but only if they also replace the function of the organ or extremity. This includes but is not limited to ostomy and urological supplies.  Repair or replacement (unless due to loss or misuse).  Rigid and semi-rigid Orthotic Devices required to support or correct a defective body part.  Tracheotomy equipment.  A wig or hairpiece to replace lost hair due to radiation therapy or chemotherapy for a covered condition, up to a lifetime benefit maximum payment of $100 per Member. We periodically update the list of approved Durable Medical Equipment, External Prosthetic Devices and Orthotic Devices to keep pace with changes in medical technology and clinical practice. To find out if a particular prosthetic or orthotic device is on our approved list for your condition, please call Member Services. Coverage is limited to the standard External Prosthetic Device or Orthotic Device that adequately meets your medical needs. Our guidelines allow you to obtain non-standard devices (those not on our approved list for your condition) if we determine that the device meets all other coverage requirements, and Medical Group or a designated physician determines that the device is Medically Necessary and that there is no standard alternative that will meet your medical needs. External Prosthetic Devices and Orthotic Devices Exclusions  Comfort, convenience, or luxury equipment or features.  Corrective Orthotic Devices such as items for podiatric use (such as shoes and arch supports, even if custom-made, except footwear described above for diabetes-related complications).  Dental appliances and dentures. EWCLGHDHP1983ACT0124 45 WAPEBB-CD-ACT