1.0 POLICY
1.1Benefits
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 services and
supplies required in the treatment of complications resulting from
a non-covered incident of treatment (such as non-adjunctive dental
care or cosmetic surgery), but only if the later complication represents
a separate medical condition such as a systemic infection, cardiac
arrest, or acute drug reaction.
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
2.1The
complication occurs in the same body system or the same anatomical
area of the noncovered treatment; andBenefits
may not be extended for any later care or a procedure related to
the complication that essentially is similar to the initial non-covered
care. Examples of complications similar to the initial episode of
care (and thus not covered) would be repair of facial scarring resulting
from dermabrasion for acne.
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.