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.
Benefits are available
for the otherwise covered 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.
2.0 EXCLUSION
S2.1 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.
Benefits 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.