Surgery
– 90%
Surgeon
Benefits
are provided for the usual, customary and reasonable charge (as determined by
this plan) for covered services performed by a physician in:
The plan uses accepted
professional guidelines as developed by the American Medical Association (AMA)
and other professional and governmental entities to determine the usual,
customary and reasonable charge for specific surgical procedures, assistant
surgeon’s fees, post-operative care, and multiple surgical procedures.
When two or more procedures are performed during one operation, secondary
procedures may be reimbursed at reduced amounts. Additional surgical procedures
that are performed as a part of the total procedure or are
“incidental” to the procedure, and pre- and post-operative care by
the operating surgeon (except to the extent it is already included in the
surgeon’s fee) are
not
covered.
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Surgical Procedures Commonly
Performed In The Physician’s Office |
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The plan does
not
cover general anesthesia or the use of a
hospital, ambulatory surgical center or other surgical facility for surgical
procedures commonly and primarily performed in a clinic or physician’s
office.
Preauthorization
with the Trust Office is required if one of these surgical procedures is to be
performed in any setting other than a clinic or physician’s office, or
under general anesthesia in any setting.
Surgical procedures commonly
performed in a physician’s office include, but are not limited
to:
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Endoscopy Procedures
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Anoscopy
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Laryngoscopy
(diagnostic)
|
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Colposcopy
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Nasal/sinus
endoscopy (diagnostic)
|
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Cystourethroscopy (separate
procedure)
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Proctosigmoidoscopy
|
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General
Surgery
|
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Aspiration/drainage of
abscess, cyst or gland
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Lesion/wart removal or
destruction
|
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Fingernail/toenail
removal
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Needle or simple
biopsy
|
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Foreign
body removal
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Sinus lavage
|
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Iridotomy/iridectomy
|
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Genito-Urinary-Gynecology
|
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Circumcision
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Vasectomy
|
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Hemorhoidectomy
(simple)
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Urethral or cervical
dilation
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Assistant
Surgeon
When a
physician, registered nurse or physician assistant renders medically necessary
surgical assistance (as determined by this plan) to the operating surgeon in
connection with a covered surgical procedure, covered expenses are limited to 20
percent of the usual, customary and reasonable charge made by the surgeon. If
such assistance is routinely available as a service provided by an intern or
resident physician of the hospital, benefits are not provided.
Anesthesia
Benefits
are provided for the services of an anesthesiologist required for a covered
surgery. Covered charges include the usual, customary and reasonable charge (as
determined by this plan) for the anesthesia. All anesthesia values are
determined by adding a “basic value” which is related to the
complexity of the service, plus “modifying units” (if any), plus
“time units.” Time units are the number of minutes which elapse
between the administration of the anesthesia and the time the individual can
safely be placed under post-operative care.
Benefits
are not
provided for the individual’s or
physician’s convenience or for fear anxiety states.
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