Welfare Summary Plan Description

5.9 SURGICAL SERVICES

The Plan provides benefits for a surgical procedure performed at a Hospital (on an inpatient or outpatient basis), or at a freestanding Outpatient Surgical Center. Included are services rendered by an assistant surgeon and Physician anesthesiologist or Registered Nurse anesthetist for anesthesia in connection with a surgical procedure.

These surgical procedures REQUIRE Precertification by the
Utilization Management Program:
All inpatient admissions
Outpatient Procedures (see below):

Abdominoplasty/Panniculectomy and Lipectomy Abdomen; these procedures are not covered if due to Gastric Bypass/Bariatric Surgery. Gastric Bypass/Bariatric Surgery is a specific exclusion under the Plan’s provisions.

Back Surgery: Discetomy, Laminectomy and Spinal Fusion; 2nd surgical opinions are appropriate on back surgeries when indicated
Breast Surgery: Breast Reconstruction, Mammoplasty (Unilat Reduction), Mammoplasty (Bilat Reduction) Hysterectomy: Abdominal Hysterectomy, Vaginal Hysterectomy, Unspecified Hysterectomy
Knee Surgery: 3 in 1 repair, 5 in 1 repair, Arthroscope, Arthrotomy, Menisectomy, Other rep of coll, other rep of knee, other repair, Patellar Stabil., Re-alignment, Revision of knee, Tendon/Patella, Total knee replacement All Nasal Surgeries
Orthognathic surgery – (Jaw and/or TMJ); TMJ is an exclusion under Plan. Uvulopharygnoplatatoplasty (UPPP), Palatopharyngoplasty
Bunionectomy and/or hammertoe (multiple) Varicose Vein Surgery
Failure to follow the required Utilization Management procedures will result in a reduction in benefits to a percentage payable of 50%, rather than the 70% that would have been payable if you followed the Plan’s required Utilization Management procedures. In addition, if services are obtained at a non-Preferred Provider facility, a 50% penalty may be applied before the 50% payment rate, as discussed below.

The surgical procedures listed below are usually performed on an outpatient basis as “same day surgery” (confinement of less than 15 consecutive hours). If any of these procedures are performed on an OUTPATIENT basis, Covered Expenses are payable at 80% if performed at a PPO facility.

If a Participant goes to an outpatient facility that is not part of the Preferred Provider network and is within a 25-mile radius of a Preferred Provider facility, the reimbursement rate will be 70%, after a 50% penalty reduction is applied. For example, if a non-Preferred Provider outpatient charge is $500, the Plan will consider only $250 of those charges ($500 less 50% = $250). In this example, the Plan will pay $175 ($250 x 70% = $175) and the Participant will pay the $325 balance.

If any of the procedures listed below are performed on an INPATIENT basis, the Plan pays 50% of Covered Expenses, unless it can be demonstrated that special risk factors exist which make surgery on an inpatient basis Medically Necessary.

AUDITORY SYSTEM
Treatment of closed or open nasal fracture
Myringotomy or tympanotomy 		DIGESTIVE SYSTEM
Liver biopsy (needle)
Repair inguinal hernia (under age 5)
INTEGUMENTARY SYSTEM
Excision of lesion or skin biopsy
Excision of nail and nail matrix
Wound repair and skin abrasion
Breast biopsy, any technique
Artery or vein ligation, simple		 MUSCULOSKELETAL SYSTEM
Reconstruction of nail bed
Tenotomy or arthrotomy
Arthoscopy, knee
Hammertoes and bunions
Fractures, simple
NERVOUS SYSTEM
Excision, benign tumor; subcutaneous
Carpal tunnel 		RESPIRATORY SYSTEM
Excision, nasal polyps
Nasal injections
ENDOSCOPY
Upper GI endoscopy
Bronchoscopy
Small bowel biopsy
Procto/proctosigmoid
Colonoscopy
Hemorrhoidectomy, simple

URINARY SYSTEM
Variocele repair
Circumcision
Urethral dilation
Meatotomy
Urethrocystography or cystourethroscopy
REPRODUCTION
Vasectomy
Tubal Ligation
Abortion

Covered Expenses for surgical or radiotherapy procedures include:

  1. Benefits payable for surgical procedures include the operation, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal uncomplicated follow-up care.
  2. Services rendered for surgery or radiotherapy by a primary operating surgeon or assisting surgeon. Benefits for a second Physician or Surgeon on the same case at the same time are payable when attendance is warranted by a need for supplementary skills.
  3. When regional or general anesthesia (not including local infiltration anesthesia) is provided by the primary operating or assisting Physician, the amount payable is determined by the “basic” value for anesthesia without added value for time.
  4. If an incidental procedure (i.e., incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst) is performed through the same incision, the benefit will be based on the major procedure only.
  5. When multiple or bilateral surgical procedures, which add significant time or complexity, are performed during the same operative session, Covered Expenses will not exceed 100% (full value) for the major procedure, plus 50% for successive non-incidental procedure(s).
  6. The services of an assistant surgeon are reimbursed up to 25% of the maximum amount payable for the primary surgeon.
  7. Covered Expenses incurred for acquisition of an organ for transplant (live or cadaveric donor), except that expenses for acquisition of an organ from an eligible Plan Participant for purposes of transplantation into another person who is not an eligible Plan Participant are not Covered Expenses under this Plan.
  8. Benefits for preoperative care, surgical procedures, and postoperative care will be based on “Surgery Guidelines” as outlined in the Physician’s Current Procedural Terminology (CPT) published by the American Medical Association, and as updated from time to time.
  9. Breast reconstruction in connection with a mastectomy. This covers reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction on the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of a mastectomy, including lymphedemas.