The Mandatory Second Surgical Opinion Program differs from the standard (optional) second opinion program in that a penalty will be imposed on payments for certain elective surgical procedures if a second opinion is not secured prior to the performance of the surgery. The penalties and/or eligible procedures are determined according to individual or group customer benefits.

The standard surgical categories included in the Mandatory Second Surgical Opinion Programs are listed on the Procedure Code Attachment.

A patient who is advised to have one of the included surgical procedures on an elective basis must obtain a second surgical opinion from a doctor who is not an associate of the first surgeon. If one of these procedures is performed and the patient has not obtained the second opinion, penalties will be imposed.

If the first and second opinions differ, a third opinion may be obtained from a third physician who is not an associate of the first or second surgeon. Even if the second (or third opinion) does not confirm the need for surgery, no penalty will be applied if the patient elects to have the surgery performed. Payment will be made for the second and/or third consultations and any necessary diagnostic tests performed in connection with the consultation.

This program is not applicable to surgery performed on a non-elective (emergency) basis.

See Medical Policy Bulletin C-8 for information regarding second surgical opinion consultations.

The above policy guidelines are not applicable.

PRN References

08/1994, Second and third surgical opinion consultations