Surgery
Chapter 4
Section 1.1
Complications (Unfortunate Sequelae) Resulting
From Noncovered Surgery Or Treatment
Issue Date: April
11, 1984
Revision:
1.0 POLICY
1.1 Benefits are
available for the otherwise covered treatment of complications resulting
from a noncovered surgery or treatment only when the complication
represents a medical condition separate from the condition that
the noncovered treatment or surgery was directed toward, and treatment
of the complication is not essentially similar to the noncovered
procedure.
1.2 A
complication may be considered a separate medical condition when
it causes a systemic effect, occurs in a different body system from
the noncovered treatment, or is an unexpected complication which
is untoward based upon prior clinical experience with the procedure.
2.0 EXCLUSIONS
2.1 The complication
occurs in the same body system or the same anatomical area of the noncovered
treatment; and
2.2 The
complication is one that commonly occurs. An example of a complication
that commonly occurs is one that occurs often enough that it is
ordinarily disclosed during the process of informed consent.
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