6.5.3
SECOND MEDICAL OPINION FOR PRE-SURGICAL REVIEW:
If the Plan requires a second medical opinion, the Utilization
Management Organization will arrange
for an examination by a Physician who:
- is certified by the American Board of Medical Specialists
in the field related to the proposed service;
- is independent of the Physician who proposed the service
; and
- will not perform the service.
The second medical opinion Physician may review past
medical records along with clinical findings from his/her
own examination of the Participant, and will report to
the Utilization Management Organization.
If the second opinion recommendation differs from the
treating Physician’s recommendation, the Plan may
obtain a third medical opinion from another Physician
who will be selected by the Utilization Management Organization.
The results of the third opinion will be reviewed by the
Utilization Management Organization, and the recommendation
of the majority of Physicians (the attending Physician,
second and third medical opinion Physicians) will prevail.
Participant-Requested Second Medical Opinion
You may request a second medical opinion in conjunction
with Pre-surgical Review requirements. If, as a result
of the second and/or third
medical opinion, it is determined that the procedure recommended
by the treating Physician is not Medically Necessary,
the Plan will not pay benefits for the proposed surgical
procedure.
If a second medical opinion is not required for Pre-surgical
Review, but you or your Dependent would like to request
one, it will be a Covered Expense.
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