Page 14 - Medicare Benefit Policy Manual
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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