Reconstructive
Surgery – 90%
Benefits are
provided for the usual, customary and reasonable charge (as determined by this
plan) for services and supplies provided by a physician for reconstructive
surgery, meaning any operative procedure, any portion of an operative procedure
or any other treatment performed solely for the purpose of correcting or
improving a bodily function as follows:
- The
repair of a congenital anomaly or a hereditary complication.
- The
repair of a defect caused by a trauma.
- The
repair of a defect caused by infection, tumor or disease.
- The
repair of a defect caused by a covered
surgery.
Some
reconstructive surgical procedures are considered cosmetic and are therefore notcovered under this plan. Questions about coverage for a proposed surgical
procedure should be directed to the Trust Office for
preauthorization.
Reconstructive
Breast Surgery
Benefits are
provided for the usual, customary and reasonable charge (as determined by this
plan) for services and supplies provided by a physician related to
reconstructive breast surgery following or coinciding with a mastectomy that is
performed as a result of an illness or injury. In accordance with the
Women’s Health and Cancer Rights Act of 1998, such benefits include
reconstruction of the breast on which the mastectomy was performed, surgery on
the other breast to produce symmetrical appearance, and prosthesis and treatment
of physical complications at all stages of mastectomy, including lymphedemas.
One external prosthesis is covered each calendar year and two mastectomy bras
are covered every six months.
Breast surgery
(excluding needle biopsy), including breast cyst removel, mammoplasty, and
mastectomy may require a second surgical opinion (please see Second
Surgical Opinion List). Benefits are
not
provided for reconstructive breast surgery for complications arising from a
cosmetic procedure such as augmentation or reduction mammoplasty.
|
|
|
