Obtaining A Second Opinion
The surgical procedures listed on page 46
represent commonly performed procedures
for which alternative treatments exist. If one
of these procedures is proposed (on an inpatient
or outpatient basis), you should tell your
physician that this plan may require a second
opinion. You must then contact the medical
review agency as soon as possible but no later
than five working days before the scheduled
surgery.
The medical review agency assesses the information
about your condition and the proposed
procedure to determine if the second opinion
is necessary. If the second opinion is necessary,
the medical review agency provides a referral
for a second opinion surgeon:
- The medical review agency maintains directories
of surgical specialists in all fields and
can recommend several located near you.
- You are then responsible for scheduling your
own appointment.
- You must use the medical review agency's
referral service for the second opinion consultation
even if your physician is a preferred
provider.
The second opinion surgeon conducts an
examination and reviews the results of any
tests or x-rays ordered by your physician. The
second opinion surgeon then makes a recommendation
to you and the medical review
agency regarding the need for the proposed
surgery, possible alternative treatment plans,
and the advisability of selected procedures
being performed on an outpatient basis. The
second surgical opinion consultation including
additional diagnostic tests, if required, are paid
at 100 percent of the usual, customary, and reasonable
charge as determined by this plan. No
deductible or coinsurance is required for the
second opinion. If the recommended surgery is
confirmed, normal benefit levels apply.
If the second opinion surgeon advises against
surgery, the plan does not cover the proposed
surgery. However, the plan will pay for a third
opinion at normal benefit levels. If the second
and third opinion physicians do not agree with
the original recommendation, the plan does
not cover the cost of the proposed surgery or
related expenses. If the second opinion surgeon
disagrees and the third opinion surgeon agrees
with the original recommendation, the medical
review agency compiles all the information
and makes its recommendation to the plan.
The plan reserves the right to determine final
medical necessity as it relates to plan benefits.
However, the choice to have surgery is always
yours.
Second Opinions While Hospitalized
If you are already hospitalized when one of
the listed surgical procedures is recommended,
you are responsible for contacting the medical
review agency. A second opinion can be
arranged at that time, if necessary.
Penalty For Not Using the Second Surgical
Opinion Program
If you do not satisfy the second surgical opinion
requirements for the listed procedures, the
plan pays the surgeonfs covered charge at 50
percent. The surgical procedure must be medically
necessary and covered by this plan.
Second Surgical Opinion List
In addition to the surgeries listed below, the
plan reserves the right to request a second
opinion for any surgery. Surgical procedures
may be added or deleted as medical standards
dictate.
- Breast surgery (excluding needle biopsy),
including breast cyst removal, mammoplasty
and mastectomy.
- Hysterectomy (removal of the uterus).
- Knee surgery by either surgical incision or
arthroscope.
- Nasal surgery, including submucous resection
and septoplasty.
- Spinal surgery, including laminectomy and
spinal fusion.
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