Page 14 - Medicare Benefit Policy Manual
P. 14

Patient-initiated second opinions that relate to the medical need for surgery or for major
                   nonsurgical diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques
                   such as cardiac catheterization and gastroscopy) are covered under Medicare.  In the
                   event that the recommendation of the first and second physician differs regarding the
                   need for surgery (or other major procedure), a third opinion is also covered.  Second and
                   third opinions are covered even though the surgery or other procedure, if performed, is
                   determined not covered.  Payment may be made for the history and examination of the
                   patient, and for other covered diagnostic services required to properly evaluate the
                   patient’s need for a procedure and to render a professional opinion.  In some cases, the
                   results of tests done by the first physician may be available to the second physician.

                   D.  Concurrent Care

                   Concurrent care exists where more than one physician renders services more extensive
                   than consultative services during a period of time.  The reasonable and necessary services
                   of each physician rendering concurrent care could be covered where each is required to
                   play an active role in the patient’s treatment, for example, because of the existence of
                   more than one medical condition requiring diverse specialized medical services.

                   In order to determine whether concurrent physicians’ services are reasonable and
                   necessary, the A/B MAC (B) must decide the following:

                       1.  Whether the patient’s condition warrants the services of more than one physician
                          on an attending (rather than consultative) basis, and

                       2.  Whether the individual services provided by each physician are reasonable and
                          necessary.

                   In resolving the first question, the A/B MAC (B) should consider the specialties of the
                   physicians as well as the patient’s diagnosis, as concurrent care is usually (although not
                   always) initiated because of the existence of more than one medical condition requiring
                   diverse specialized medical or surgical services.  The specialties of the physicians are an
                   indication of the necessity for concurrent services, but the patient’s condition and the
                   inherent reasonableness and necessity of the services, as determined by the A/B MAC
                   (B)’s medical staff in accordance with locality norms, must also be considered.  For
                   example, although cardiology is a sub-specialty of internal medicine, the treatment of
                   both diabetes and of a serious heart condition might require the concurrent services of
                   two physicians, each practicing in internal medicine but specializing in different sub-
                   specialties.

                   While it would not be highly unusual for concurrent care performed by physicians in
                   different specialties (e.g., a surgeon and an internist) or by physicians in different
                   subspecialties of the same specialty (e.g., an allergist and a cardiologist) to be found
                   medically necessary, the need for such care by physicians in the same specialty or
                   subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in
                   most cases both physicians would possess the skills and knowledge necessary to treat the
   9   10   11   12   13   14   15   16   17   18   19