Obtaining A Second Opinion

The surgical procedures listed represent commonly performed procedures for which alternative treatments exist. If one of these procedures is proposed (on an inpatient or outpatient basis), an individual should tell the physician that this plan may require a second opinion. The individual 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 the individual’s 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 the individual, if they decide a second opinion is necessary.
• The individual is then responsible for scheduling his or her own appointment.
• The individual must use the medical review agency’s referral service for his or her second opinion consultation even if the individual’s physician is a preferred provider.

The second opinion surgeon conducts an examination and reviews the results of any tests or x-rays ordered by the individual’s physician. The second opinion surgeon then makes a recommendation to the individual 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 the individual’s.

Second Opinions While Hospitalized

If an individual is already in the hospital when surgery for one of the listed procedures is recommended, the individual is 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 an individual does not satisfy the second surgical opinion requirements for the listed procedures, the plan pays the surgeon’s 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.
• Carotid endarterectomy (removal of the inner layer of the carotid artery).
• Coronary artery bypass.
• 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.