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     Home → Welfare→ SPD → 6.5.3 SECOND MEDICAL OPINION FOR PRE-SURGICAL REVIEW:

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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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