Health & Security Retiree Health Plan > SPD > Surgery

Summary Plan Description

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:

  • A physician's office (please see "Surgical Procedures Commonly Performed In the Physician's Office" on page 82).
  • An approved outpatient or same-day surgical center.
  • An approved ambulatory surgical center.
  • An approved hospital.

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.

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), a second surgical opinion may be required (please see "Second Surgical Opinion Program" on pages 44-46).

Surgical Procedures Commonly Performed in the Physicians Office

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.
Endoscopic Procedures

Anoscopy

Laryngoscopy (diagnostic)

Colposcopy

Nasal/sinus endoscopy (diagnostic)

Cystourethroscopy (separate procedure)

Proctosigmoidoscopy

General Surgery

Aspiration/drainage of abscess, cyst or gland

Lesion/wart removal or destruction

Fingernail/toenail removal

Needle or simple biopsy

Foreign body removal

Sinus lavage

Iridotomy/iridectomy

 

Genito-Urinary-Gynecology

Circumcision

Vasectomy

Hemorhoidectomy (simple)

Urethral or cervical dilation

Helpful Hint

You may request a benefit estimate before the operation is performed by requesting the proposed Physicians' Current Procedural Terminology or CPT code from the physician or surgeon. The CPT code identifies surgical complexity, physical findings (such as size and location), concurrent medical problems, and includes anticipated post-operative follow-up care. The surgeon should also be able to quote a fee up front. With this information, the Trust Office can provide you with an estimate of what will be allowed for that surgical procedure, although actual payment is based on the submitted claim.

Assistant Surgeon

When a physician, registered nurse (covered for non-Medicare patients 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.