Highmark Commercial Medical Policy - Pennsylvania

Medical Policy: C-6-024
Topic: Mandatory Second Surgical Opinion
Section: Consultations
Effective Date: January 1, 2012
Issue Date: July 23, 2018
Last Reviewed: June 2018

The Mandatory Second Surgical Opinion Program imposes payments for certain elective surgical procedures if a second opinion is not secured prior to the performance of the surgery.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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 located on the table attachment link.

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.

Procedure Codes
99241, 99242, 99243, 99244, 99245, 99251 , 99252, 99253, 99254, 99255

Place of Service: Inpatient/Outpatient

Mandatory Second Surgical Opinion is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.