Surgical and Other Georgia Lumenos Health Insurance Plan Coverage

Second Surgical Opinion

Coverage is provided for an opinion provided by a second physician, when one physician recommends surgery to an individual. Second opinions will be covered at 90% for providers who offer discounts, and 60% for providers who do not offer discounts.

Surgery

Coverage is provided for surgery rendered in both inpatient and outpatient settings for the treatment of disease or injury. Separate payment will not be made for pre-operative care or post-operative care normally provided by the surgeon as part of the surgical procedure.

NOTE: Prior authorization is required for:

• Medical necessity for procedures that could be considered cosmetic
• Transplants

Breast reconstruction coverage

Other covered services also include breast reconstruction - for you and your covered dependents - if you or your family members received benefits for a mastectomy, and/or elected breast reconstruction in connection with the mastectomy. As long as the breast reconstruction is performed in a manner determined by the patient in consultation with the attending physician, benefits include:

• Reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas.

Surgical Services

Coverage is provided for the following surgical services:

• Assistant Surgeon
• Bilateral Surgical Procedures
• Co-surgeon
• Multiple Surgical Procedures

Assistant Surgeon

Benefits may be provided for services of a physician who actively assists the operating surgeon when it is determined that the condition of the patient or the type of surgical service requires such assistance.

When considered necessary by the surgeon, the service of an assistant surgeon is a covered service. The benefit payable for the assistant surgeon's services is 20% of the benefit payable for the primary surgeon.

Bilateral Surgical Procedures

Bilateral surgical procedures are defined as more than one procedure associated with a single surgical event. For bilateral procedures, the plan considers 50% of the eligible benefit for the primary surgical procedure.

Co-Surgeon

A co-surgeon is usually a surgeon who is in the operating room performing a different surgery than the other surgeon who is present at the same time. Also, a co-surgeon is allowed in complicated surgeries (such as heart surgery) due to the length of time of the operation. The co-surgeons have the same responsibility. Co-surgeon services are covered at 50% of the eligible benefit of the surgeon's fee.

Multiple Surgical Procedures

For multiple surgeries (related operations or procedures performed through the same incision or in the same operative field, performed at the same operative session), the plan considers as an eligible expense 100% of the eligible surgical allowance for the highest paying procedure plus 50% of the eligible surgical allowance for the second highest paying procedure and 50% of the eligible surgical allowance for each additional procedure. For example, if the benefit normally pays 90%, the primary surgical procedure would be paid at 90%, the remaining surgical procedures would be paid at 50% of the 90% benefit.

Temporomandibular Joint Dysfunction (TMJ)

Coverage is provided for surgical treatment of temporomandibular joint dysfunction if due to accident, congenital defect or developmental defect. Appliances are limited to a $1,100 lifetime maximum.

Therapy Services

Coverage is provided for therapy services when used for the treatment of a condition, sickness or injury to promote the recovery of the covered person. To be covered, the therapy services must be rendered in accordance with a physician's written treatment plan. Services covered under the Lumenos plan include:

• Chemotherapy - the treatment of malignant disease by chemical or biological antineoplastic agents. The cost of the antineoplastic agent is included.
• Dialysis Treatment - the treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body, to include hemodialysis or peritoneal dialysis.
• Occupational Therapy - the treatment of a physically disabled person by means of constructive activities designed and adapted to promote the functional restoration of the person's abilities lost or impaired by disease or accidental injury, to satisfactorily accomplish the ordinary tasks of daily living. Occupational therapy is limited to 40 visits per person per Plan year.
• Physical Therapy - the treatment by physical means, hydrotherapy, heat, or similar modalities; physical agents; bio-mechanical and neuro-physical principles; and devices to relieve pain, restore maximum function lost or impaired by disease or accidental injury, and prevent disability following disease, injury or loss of body part. Physical therapy is limited to 40 visits per person per Plan year.
• Radiation Therapy - the treatment of disease by X-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.
• Respiratory Therapy - the introduction of dry or moist gases into the lungs for treatment purposes.
• Speech Therapy - Speech therapy is covered to restore speech loss or correct impairment due to a congenital defect, illness or injury; such as stroke, head injury or vocal cord injury. Speech therapy is limited to 40 visits per person per Plan year.

Transplant Services

Coverage is provided for the expenses for human to human organ or tissue transplants including:

• Kidney
• Heart/lung
• Cornea
• Liver
• Bone marrow/Stem cell
• Pancreas
• Heart
• Lung
• Kidney/pancreas
• Liver/small bowel
• Small bowel

Covered expenses incurred by the donor of an organ or tissue for transplant to a recipient who is a covered person under this Plan are covered the same as any other sickness when the donor is a covered person under this Plan.

Covered expenses incurred by the donor of an organ or tissue for transplant when the donor is not a covered person under this Plan are covered to the extent of any benefits remaining after payment of the covered person's expenses as a recipient, when the donor's expenses are not covered under any group or individual insurance policy or benefit plan and are charged to the recipient.

Covered expenses include:

• Organ or tissue procurement from a cadaver consisting of removing, preserving and transporting the donated part;
• Services and supplies furnished by a facility provider;
• Treatment and surgery by a professional provider; and
• Drug therapy treatment to prevent rejection of the transplanted organ or tissue.

Surgical, storage and transportation costs directly related to the procurement of an organ or tissue used in a transplant described above will be covered for each such procedure completed. If an organ or tissue is sold rather than donated, no benefits will be available for the purchase price of such organ or tissue. If a covered transplant procedure is not done as scheduled due to the intended recipient's medical condition or death, benefits will be paid for charges incurred for organ or tissue procurement as described above.

You must contact the plan in order for care to be precertified prior to services occurring. Benefits for transplants are limited to $500,000 lifetime maximum for all services other than kidney or cornea transplant.

Coverage is provided for transplant recipients and family members for the cost of travel and lodging. There is a combined episodic maximum of $10,000 per covered person. This maximum applies to all associated transportation, lodging and meal expenses incurred by the transplant recipient and companion(s). Benefits for transplant - transportation and lodging are covered at 100% of charges only when treatment is rendered in a facility that offers discounts.

The Lumenos plan covers the following expenses:

• Transportation for the patient and a companion traveling on the same day(s) to and/or from the site of the transplant for the evaluation, transplant procedure, or necessary post-discharge follow-up.
• Reasonable and necessary expenses for lodging and meals for the patient (while not hospitalized) and companion. Benefits are paid at a rate of up to $50 per day for one person. If the patient is a dependent child, the transportation expenses of two companions will be covered, and lodging and meal expenses will be reimbursed up to $100 each day.
• Travel and lodging expenses - but only if the transplant recipient resides more than 50 miles from the designated transplant facility.