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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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