5.8 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.
However, the Plan covers expenses for non-emergency orthopedic or podiatric surgery expenses only if provided through BridgeHealth or a Preferred Provider. Other non-emergency orthopedic or podiatric surgery expenses are not covered by this Plan, and do not count toward the Plan’s out-of-pocket limits.
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 75-mile radius of a Preferred Provider facility, the reimbursement rate will be 60%, 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 $150 ($250 x 60% = $150) and the Participant will pay the $350 balance. If the service is for non-emergency orthopedic or podiatric surgery performed by a non-Preferred Provider, $0 (zero) will be paid by the Plan.
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.
Treatment of closed or open nasal fracture
Myringotomy or tympanotomy
Liver biopsy (needle)
Repair inguinal hernia (under age 5)
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
Reconstruction of nail bed
Tenotomy or arthrotomy
Hammertoes and bunions
Excision, benign tumor; subcutaneous
Excision, nasal polyps
Upper GI endoscopy
Small bowel biopsy
Urethrocystography or cystourethroscopy
Covered Expenses for surgical or radiotherapy procedures include:
- Benefits payable for surgical procedures include the operation, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal uncomplicated follow-up care.
- 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.
- 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.
- 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.
- 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).
- The services of an assistant surgeon are reimbursed up to 25% of the maximum amount payable for the primary surgeon.
- 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.
- 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.
- 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.