High and Standard Option    

Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals

Subsections:

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is: $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option. The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
  • The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
  • YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to page 40 for information regarding Organ/tissue transplants.

Benefit Description
You Pay

After the calendar year deductible...

NOTE: The calendar year deductible applies to almost all benefits in this Section.
We say "(No deductible)" when it does not apply.
Surgical Procedures
High Option
Standard Option
A comprehensive range of services, such as:
  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Voluntary sterilization (e.g., tubal ligation, vasectomy).
  • Surgically implanted contraceptives
  • Surgical treatment of morbid obesity (bariatric surgery) – Preauthorization of this procedure is required. Contact CIGNA/CareAllies at 1-800/887-9735. The Plan’s criteria includes the following:
    • Eligible patients must be age 18 or over
    • The patient has a documented body mass index (BMI) of 40 or greater and documented failure to sustain weight loss with medically supervised dietary and conservative treatment for a total of 12 months or a 6 month multidisciplinary approach (physician, dietician and physical therapy) within the two years preceding surgery
    • The patient has a BMI over 40 and at least one co-morbidity such as hypertension, type 2 diabetes, cardiovascular disease, respiratory compromise related to obesity, or other medical conditions that have a morbid effect on the clinical course and are related to or accentuated by obesity
    • A repeat or revised bariatric surgical procedure is covered only when medically necessary or a complication has occurred
  • Intrauterine devices (IUDs)
  • Treatment of burns
  • Assistant surgeons – we cover up to 20% of our allowance for the surgeon’s charge
PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an assistant surgeon who is not a PPO provider. 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an assistant surgeon who is not a PPO provider.
When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:
  • For the primary procedure:
     - Full Plan allowance
  • For the secondary procedure(s):
     - One half of the Plan allowance
Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures. 		PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of the Plan allowance for the secondary procedure(s)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount		 PPO: 15% of the Plan allowance for the primary procedure and 15% of one-half of the Plan allowance for the secondary procedure(s)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount
Not covered:
  • Reversal of voluntary sterilization
  • Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically necessary
  • Routine treatment of conditions of the foot; see Foot care
 Eye surgery, such as radial keratotomy, lasik and laser surgery when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring) 		All charges All charges
Reconstructive surgery

 

 
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery to produce a symmetrical appearance of breasts;
    • treatment of any physical complications, such as lymphedemas;
    • breast prostheses; and surgical bras and replacements (see Orthopedic and prosthetic devices for coverage)
Note: We pay for internal breast prostheses as orthopedic and prosthetic devices, see Section 5(a)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the admission. 		PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

 PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
  • Surgeries related to sex transformation or sexual dysfunction
 		All charges All charges
Oral and maxillofacial surgery
    
Oral surgical procedures, limited to:
  • Reduction of fractures of the jaws or facial bones
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion
  • Removal of stones from salivary ducts
  • Excision of impacted teeth, bony cysts of the jaw, torus palatinus, leukoplakia, or malignancies
  • Excision of cysts and incision of abscesses not involving the teeth
  • Other surgical procedures that do not involve the teeth or their supporting structures
  • Freeing of muscle attachments
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

 PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges All charges
Organ/tissue transplants

 

 
Solid organ transplants are limited to:
  • Cornea
  • Heart
  • Heart/lung
  • Kidney
  • Liver
  • Pancreas
  • Single, double or lobar lung
  • Intestinal transplants
    • Small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant
Blood or marrow stem cell transplants limited to the stages of the following diagnoses (the medical necessity limitation is considered satisfied if the patient meets the staging description):
  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Chronic myelogenous leukemia
    • Hemoglobinopathy (i.e., Fanconi’s, Thalessemia major)
    • Myelodysplasia/Myelodysplastic syndromes
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Amyloidosis
  • Autologous transplants for:
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Advanced Neuroblastoma
    • Amyloidosis
  • Autologous tandem transplants for:
    • recurrent germ cell tumors (including testicular cancer)
    • Multiple myeloma
    • De-novo myeloma
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant
Blood or marrow stem cell transplants for
  • Allogeneic transplants for:
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Leukocyte adhesion deficiencies
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hurler’s syndrome, Matoteaux-Lamy syndrome variants)
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for:
    • Multiple myeloma
    • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
    • Breast cancer
    • Epithelial ovarian cancer
    • Pineoblastoma
    • Waldenstrom’s macroglobulinemia
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant
Blood or marrow stem cell transplants covered only in a National Cancer Institute or National Institutes of Health approved clinical trial for:
  • Allogeneic transplants for:
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Myelodysplasia/myelodysplastic syndromes
    • Multiple myeloma
  • Nonmyeloablative allogeneic transplants for:
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan pays $100,000 per transplant
Covered expenses for the purpose of this benefit are:
  • The pretransplant evaluation;
  • Organ procurement;
  • The transplant procedure itself (hospital and doctor fees);
  • Transplant-related follow-up care for up to one year from the date the transplant procedure is performed; and
Pharmacy costs for immunosuppressant and other transplant-related medication. 		   
The Plan uses specific Plan-designated organ/tissue transplant facilities. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact the CareAllies CIGNA LIFESOURCE Transplant Unit at 1-800/668-9682 to initiate the pretransplant evaluation. The clinical results of the evaluation will be reviewed to determine if the proposed procedure meets the Plan’s definition of medically necessary. A case manager will assist the patient in accessing the appropriate transplant facility. If you choose a Plan-designated transplant facility, the Plan will provide an allowance for preapproved reasonable travel and lodging costs (see Travel/Lodging Benefit below).

Note: We cover related medical and hospital expenses of the actual donor for the initial transplant confinement when we cover the recipient, if these expenses are not covered by any other health plan.

Travel/Lodging Benefit – If the recipient lives more than 50 miles from a Plan-designated transplant facility, the Plan will provide an allowance for preapproved travel and lodging expenses up to $10,000 per transplant. The allowance will provide coverage of reasonable travel and temporary lodging expenses for the recipient and one companion (two companions if the recipient is a minor) and the actual organ donor, if applicable.

Limited Benefits – If you do not use a Plan-designated transplant facility total benefit payments, including donor expenses, the transplant procedure itself (hospital and doctor fees), transplant-related follow-up care for one year from the date the transplant procedure is performed, and pharmacy costs for immunosuppressant and other transplant-related medication will be limited to a maximum payment of $100,000 per transplant. The travel and lodging allowance will not be available. 		   
Not covered:
  • Donor screening tests and donor search expenses, except those performed for the actual donor
  • Implants of artificial organs
  • Transplants and related services not listed as covered

All charges

All charges

Anesthesia
 		   
Professional services provided in –
  • Hospital (inpatient)
 PPO: 10% of the Plan allowance (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an anesthesiologist who is not a PPO provider. 		PPO: 15% of the Plan allowance (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an anesthesiologist who is not a PPO provider.
Professional services provided in –
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgical center
  • Office
 PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an anesthesiologist who is not a PPO provider. 		PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Note: If you use a PPO facility, we pay PPO benefits if you receive treatment from an anesthesiologist who is not a PPO provider.