Medical Plan Definitions
Annual deductible
The amount you must pay for covered services in a calendar year before the Plan begins paying benefits in that calendar year.
Assisted Reproductive Technology (ART)
The comprehensive term for procedures involving the manipulation of human reproductive materials (such as sperm, eggs, and/or embryos) to achieve pregnancy. Examples of such procedures are:
  • In vitro fertilization (IVF).
  • Gamete intrafallopian transfer (GIFT).
  • Pronuclear stage tubal transfer (PROST).
  • Tubal embryo transfer (TET).
  • Zygote intrafallopian transfer (ZIFT).
Autism spectrum disorders
A condition marked by enduring problems communicating and interacting with others, along with restricted and repetitive behavior, interests or activities.
Cellular Therapy
Administration of living whole cells into a patient for the treatment of disease.
Claims administrator
UnitedHealthcare (also known as United HealthCare Services, Inc.) and its affiliates, who provide certain claim administration services for the Plan (e.g., UnitedHealthcare is responsible for making claim payments according to the terms of the Plan).
Clinical Trials
With respect to cancer or other life-threatening diseases or conditions, a qualifying clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention or treatment of cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted list below.
With respect to cardiovascular disease or musculoskeletal disorders of the spine and hip and knees and other diseases or disorders which are not life-threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III clinical trial that is conducted in relation to the detection or treatment of such non-life-threatening disease or disorder and which meets any of the following criteria in the bulleted list below.
  • Federally funded trials. the study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
    • National Institute of Health (NIH). (Includes National Cancer Institute (NCI)
    • Centers for Disease Control and Prevention (CDC)
    • Agency for Healthcare Research and Quality (AHRQ)
    • Centers for Medicare and Medicaid Services (CMS)
    • A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA)
    • A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants, or
    • The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:
      • Comparable to the system of peer review of studies and investigations used by the National Institute of Health, and
      • Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
  • The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration
  • The study or investigation is a drug trial that is exempt from having such an investigational new drug application
  • The clinical trial must have written protocol that describes a scientifically sound study and have been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. The Plan may, at any time, request documentation about the trial, or
  • The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a covered health service and is not otherwise excluded under the Plan.
Coinsurance
The percentage of eligible expenses you are required to pay toward the cost of certain covered services.
Congenital anomaly
A physical developmental defect that is present at birth and is identified within the first twelve months after birth.
Copayment
The flat dollar charge you are required to pay for office visits and emergency room services.
Cosmetic procedures
Procedures or services that change or improve appearance without significantly improving physiological function, as determined by UnitedHealthcare. Reshaping a nose with a prominent bump is a good example of a cosmetic procedure because appearance would be improved, but there would be no improvement in physiological function, for example breathing.
Covered health services
Those health services, including services, supplies or pharmaceutical products, which UHC determines to be:
  • Provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, Injury, mental illness, substance-related and addictive disorders, condition, disease or its symptoms.
  • Medically Necessary.
  • Described under "Covered Medical Expenses"
  • Provided to a covered person who meets the Plan's eligibility requirements, as described in the SPD,
  • Not otherwise excluded in this SPD under "Expenses Not Covered."
Custodial care
Services that:
  • Are non-health related, such as assistance in activities of daily living including, but not limited to, feeding, dressing, bathing, transferring and ambulating
  • Are health-related services which do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing
  • Do not require continued administration by trained medical personnel in order to be delivered safely and effectively
Definitive Drug Test
Test to identify specific medications, illicit substances and metabolites and is qualitative or quantitative to identify possible use or non-use of a drug.
Designated Network Benefits
The description of how benefits are paid for the covered health services provided by a physician or other provider that has been identified as a Designated Provider.
Designated Provider
A provider and/or facility that:
  • Has entered into an agreement with UnitedHealthcare, or with an organization contracting on UnitedHealthcare's behalf, to provide covered health services for the treatment of specific diseases or conditions; or
  • UnitedHealthcare has identified through UnitedHealthcare's designation programs as a Designated Provider. Such designation may apply to specific treatments, conditions and/or procedures.
A Designated Provider may or may not be located within your geographic area. Not all in-network hospitals or physicians are Designated Providers.
You can find out if your provider is a Designated Provider by contacting UnitedHealthcare at www.myuhc.com or the telephone number on your ID card.
Durable medical equipment
Medical equipment that meets all of the following conditions:
  • Can withstand repeated use
  • Is not disposable
  • Is used to serve a medical purpose with respect to treatment of a sickness or injury or their symptoms
  • Is generally not useful to a person in the absence of a sickness or injury
  • Is appropriate for use in the home
  • Is not implantable within the body
Eligible expenses
For covered health services, incurred while the Plan is in effect, eligible expenses are determined by UnitedHealthcare as stated below and as detailed in "Eligible Expenses."
Eligible expenses are determined solely in accordance with UnitedHealthcare's reimbursement policy guidelines. UnitedHealthcare develops the reimbursement policy guidelines, in their discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies:
  • As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).
  • As reported by generally recognized professionals or publications.
  • As used for Medicare.
As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that UnitedHealthcare accepts.
Emergency
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:
  • Placing the health of the covered person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
  • Serious impairment to bodily functions.
  • Serious dysfunction of any bodily organ or part.
Emergency Health Services
With respect to an emergency, both of the following:
  • A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency.
  • Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
Experimental or investigational services
Medical, surgical, diagnostic, psychiatric, mental health, substance-related and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time UnitedHealthcare makes a determination regarding coverage in a particular case, are determined to be any of the following:
  • Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use.
  • Subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational.)
  • The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.
Exceptions:
  • Clinical trials for which benefits are available as described under the definition of "Clinical Trials" above.
  • If you are not a participant in a qualifying clinical trial as described above, and have a sickness or condition that is likely to cause death within one year of the request for treatment, UnitedHealthcare may, at its discretion, consider an otherwise experimental or investigational service to be a covered health service for that sickness or condition. Prior to such consideration, UnitedHealthcare must determine that, although unproven, the service has significant potential as an effective treatment for that sickness or condition.
Fertility Solutions (FS)
A program administered by UnitedHealthcare or its affiliates. The FS program provides:
  • Specialized clinical consulting services to covered employees and enrolled dependents to educate on fertility treatment options.
  • Access to specialized network facilities and physicians for fertility services.
Gender Dysphoria
A disorder characterized by the following diagnostic criteria classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association:
Diagnostic criteria for adults and adolescents:
  • A marked incongruence between one's experienced/expressed gender and assigned gender, of at least six months' duration, as manifested by at least two of the following:
    • A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
    • A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
    • A strong desire for the primary and/or secondary sex characteristics of the other gender.
    • A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
    • A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
    • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).
  • The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.
  • Diagnostic criteria for children: A marked incongruence between one's experienced/expressed gender and assigned gender, of at least six months' duration, as manifested by at least six of the following (one of which must be criterion as shown in the first bullet below):
    • A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one's assigned gender).
    • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    • A strong preference for cross-gender roles in make-believe play or fantasy play.
    • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.
    • A strong preference for playmates of the other gender.
    • In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
    • A strong dislike of ones' sexual anatomy.
    • A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.
The condition is associated with clinically significant distress or impairment in social, school or other important areas of functioning.
Genetic Counseling
Counseling by a qualified clinician that includes:
  • Identifying your potential risks for suspected genetic disorders;
  • An individualized discussion about the benefits, risks and limitations of Genetic Testing to help you make informed decisions about Genetic Testing; and
  • Interpretation of the Genetic Testing results in order to guide health decisions.
  • Certified genetic counselors, medical geneticists and physicians with a professional society's certification that they have completed advanced training in genetics are considered qualified clinicians when covered health services for Genetic Testing require Genetic Counseling.
Genetic Testing
Exam of blood or other tissue for changes in genes (DNA or RNA) that may indicate an increased risk for developing a specific disease or disorder, or provide information to guide the selection of treatment of certain diseases, including cancer.
Gene Therapy
Delivery of nucleic acid (DNA or RNA) into a patient's cells as a drug to treat a disease.
Gestational Carrier
A Gestational Carrier is a female who becomes pregnant by having a fertilized egg (embryo) implanted in her uterus for the purpose of carrying the fetus to term for another person. The carrier does not provide the egg and is therefore not biologically (genetically) related to the child.
Home health agency
A program or organization authorized by law to provide healthcare services in the home.
Hospital
An institution, operated as required by law, which meets both of the following conditions:
  • Is primarily engaged in providing health services, on an inpatient basis, for the acute care and treatment of injured or sick individuals (Care is provided through medical, diagnostic and surgical facilities, by or under the supervision of a staff of physicians.)
  • Has 24-hour nursing services
Infertility
A disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery. It is defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women age 35 years or older.
Inpatient stay
An uninterrupted confinement, following formal admission to a hospital, skilled nursing facility or inpatient rehabilitation facility.
Intensive Behavioral Therapy (IBT)
Outpatient behavioral/educational services that aim to reinforce adaptive behaviors, reduce maladaptive behaviors and improve the mastery of functional age appropriate skills in people with Autism Spectrum Disorders. Examples include Applied Behavioral Analysis (ABA), The Denver Model, and Relationship Development Intervention (RDI).
Intensive Outpatient Treatment
A structured outpatient mental health or substance-related and addictive disorders treatment program that may be free-standing or hospital-based and provides services for at least three hours per day, two or more days per week.
Maximum Out-of-network Reimbursement (MNRP)
This program establishes a benchmark for payment, including use of rates and methodologies established by Medicare to reimburse non-emergency claims. Stryker's Health and Welfare Plan pays based on 140% of these Medicare established fee limits.
Medically Necessary
Health care services that are all of the following as determined by UnitedHealthcare or its designee, within UnitedHealthcare's sole discretion. The services must be:
  • In accordance with Generally Accepted Standards of Medical Practice.
  • Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for your sickness, injury, mental illness, substance-related and addictive disorders disease or its symptoms.
  • Not mainly for your convenience or that of your doctor or other health care provider.
  • Not more costly than an alternative drug, service(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.
Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.
If no credible scientific evidence is available, then standards that are based on physician specialty society recommendations or professional standards of care may be considered. UnitedHealthcare reserves the right to consult expert opinion in determining whether health care services are medically necessary. The decision to apply physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within UnitedHealthcare's sole discretion.
UnitedHealthcare develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. These clinical policies (as developed by UnitedHealthcare and revised from time to time), are available to covered persons on www.myuhc.com or by calling the number on your ID card, and to physicians and other health care professionals on www.UHCprovider.com.
Medicare
Parts A, B, C and D of the insurance program established by Title XVIII of the United States Social Security Act, and as later amended.
Mental health services
Services for the diagnosis and treatment of those mental health or psychiatric categories that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or the Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a condition is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a covered health service.
Mental illness
Those mental health or psychiatric diagnostic categories listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a condition is listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a covered health service.
Neonatal Resource Services (NRS)
A program administered by UnitedHealthcare or its affiliates made available to you by Stryker. The NRS program provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to help manage NICU admissions.
Network (also called in-network)
When used to describe a provider of healthcare services, this means a provider that has a participation agreement in effect with UnitedHealthcare or an affiliate to provide covered health services to covered members. The participation status of providers will change from time to time.
Network benefits
Benefits for covered health services that are provided by a network physician or other network provider.
Non-Medical 24-Hour Withdrawal Management
An organized residential service, including those defined in American Society of Addiction Medicine (ASAM), providing 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal, using peer and social support rather than medical and nursing care
Out-of-network benefits
Benefits for covered health services that are provided by an out-of-network physician or other out-of-network provider.
Personal Health Nurse
The primary nurse that UnitedHealthcare may assign to you if you have a chronic or complex health condition. If a Personal Health Nurse is assigned to you, this nurse will call you to assess your progress and provide you with information and education.
Pharmaceutical Product(s)
U.S. Food and Drug Administration (FDA)-approved prescription medications or products administered in connection with a Covered Health Service by a Physician.
Pharmaceutical Products (New)
A pharmaceutical product or new dosage form of a previously approved pharmaceutical product for the period of time starting on the date the pharmaceutical product or new dosage form is approved by the U.S. Food and Drug Administration (FDA) and ends on the earlier of the following dates.
  • The date it is reviewed.
  • December 31st of the following calendar year.
Physician
Any Doctor of Medicine, "M.D.," or Doctor of Osteopathy, "D.O.," who is properly licensed and qualified by law. Any podiatrist, dentist, psychologist, chiropractor, optometrist or other provider who acts within the scope of his or her license is considered on the same basis as a physician. The fact that a provider is described as a physician does not mean that benefits for services provided by that provider are available under the Plan.
Plan
The Stryker Corporation Welfare Benefits Plan.
Pregnancy
Includes all of the following:
  • Prenatal care
  • Postnatal care
  • Childbirth
  • Any complications associated with pregnancy
Presumptive Drug Test
Test to determine the presence or absence of drugs or a drug class in which the results are indicated as negative or positive result.
Private Duty Nursing
Nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or home setting when any of the following are true:
  • Services exceed the scope of Intermittent Care in the home.
  • The service is provided to covered person by an independent nurse who is hired directly by the covered person or his/her family. This includes nursing services provided on an inpatient or home-care basis, whether the service is skilled or non-skilled independent nursing.
  • Skilled nursing resources are available in the facility.
  • The Skilled Care can be provided by a Home Health Agency on a per visit basis for a specific purpose.
Qualified medical child support order (QMCSO)
Any judgment, order or decree issued by a court or state administrative agency that:
  • Provides for child support with respect to a plan participant's child or directs the participant to provide coverage under a health benefits plan due to a state domestic relations law, or
  • Enforces a law relating to medical child support described in the Social Security Act, Section 1908, with respect to a group health plan and which satisfies the requirements to be a QMCSO set out in Section 609 of ERISA.
Shared Savings Program
A program in which UnitedHealthcare may obtain a discount to an out-of-network provider's billed charges. This discount is usually based on a schedule previously agreed to by the out-of-network provider. When this happens, you may experience lower out-of-pocket amounts. Plan coinsurance and any applicable deductible would still apply to the reduced charge. Sometimes Plan provisions or administrative practices supersede the scheduled rate, and a different rate is determined by UnitedHealthcare. This means, when contractually permitted, the Plan may pay the lesser of the Shared Savings Program discount or an amount determined by UnitedHealthcare such as a percentage of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for the same or similar service within the geographic market, an amount determined based on available data resources of competitive fees in that geographic area, a fee schedule established by a third party vendor or a negotiated rate with the provider. In this case the out-of-network provider may bill you for the difference between the billed amount and the rate determined by UnitedHealthcare. If this happens you should call the number on your ID Card. Shared Savings Program providers are not network providers and are not credentialed by UnitedHealthcare.
Sickness
Physical illness, disease or pregnancy. The term sickness as used in this SPD includes mental illness, or substance-related and addictive disorders, regardless of the cause or origin of the mental illness, or substance-related and addictive disorder.
Skilled nursing facility
A hospital or nursing facility that is licensed and operated as required by law.
Substance-related and addictive disorder services
Services for the diagnosis and treatment of alcoholism and substance-related and addictive disorders that are listed in the current edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a disorder is listed in the edition of the International Classification of Diseases section on Mental and Behavioral Disorders or Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a covered health service.
Surrogate
A female who becomes pregnant usually by artificial insemination or transfer of a fertilized egg (embryo) for the purpose of carrying the fetus for another person. The surrogate provides the egg and is therefore biologically (genetically) related to the child.
Therapeutic Donor Insemination (TDI)
Insemination with a donor sperm sample for the purpose of conceiving a child.
Transitional Living
Mental Health Services and Substance-Related and Addictive Disorders Services that are provided through facilities, group homes and supervised apartments that provide 24-hour supervision, including those defined in American Society of Addiction Medicine (ASAM) criteria, that are either:
  • Sober living arrangements such as drug-free housing or alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist the covered person with recovery.
  • Supervised living arrangements which are residences such as facilities, group homes and supervised apartments that provide stable and safe housing and the opportunity to learn how to manage activities of daily living. Supervised living arrangements may be utilized as an adjunct to treatment when treatment doesn't offer the intensity and structure needed to assist the covered person with recovery.
UHC Health Advantage
Programs provided by the UnitedHealthcare that focus on prevention, education, and closing the gaps in care designed to encourage an efficient system of care for you and your covered dependents.
UnitedHealth Premium Program
A program that identifies network physicians or facilities that have been designated as a UnitedHealth Premium Program Physician or facility for certain medical conditions. To be designated as a UnitedHealth Premium provider, physicians and facilities must meet program criteria. The fact that a physician or facility is a network physician or facility does not mean that it is a UnitedHealth Premium Program physician or facility.
Unproven services
Health services, including medications that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.
  • Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received).
  • Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.
UnitedHealthcare has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, UnitedHealthcare issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.
Please note:
  • If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare may, at its discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition. Prior to such a consideration, UnitedHealthcare must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition.
The decision about whether such a service can be deemed a covered health service is solely at UnitedHealthcare's discretion. Other apparently similar promising but unproven services may not qualify.
Urgent Care
Care that requires prompt attention to avoid adverse consequences, but does not pose an immediate threat to a person's life. Urgent care is usually delivered in a walk-in setting and without an appointment. Urgent care facilities are a location, distinct from a hospital emergency department, an office or a clinic. The purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
Urgent Care Center
A facility that provides covered health services that are required to prevent serious deterioration of your health, and that are required as a result of an unforeseen sickness, injury, or the onset of acute or severe symptoms.