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 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
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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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Endoscopic
Procedures
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Anoscopy
Colposcopy
Cystourethroscopy
(separate procedure)
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Laryngoscopy
(diagnostic)
Nasal/sinus
endoscopy
(diagnostic)
Proctosigmoidoscopy
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General
Surgery
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Aspiration/drainage
of abscess, cyst or
gland
Fingernail/toenail
removal
Foreign body
removal
Iridotomy/iridectomy
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Lesion/wart
removal or
destruction
Needle or
simple biopsy
Sinus
lavage
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Genito-Urinary-Gynecology
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Circumcision
Hemorrhoidectomy
(simple)
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Vasectomy
Urethral
or cervical dilation
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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.
Assistant
Surgeon
When a
physician, registered nurse (covered for non-Medicare individuals only) 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.
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