PURPOSE: This rule implements the requirement that a second medical opinion must be obtained before Medicaid will pay for certain nonemergency, elective surgical procedures and the related costs of these surgical procedures.

1. (1) Effective October 1, 1981 certain nonemergency, elective surgical procedures specified by the Division of Family Services, when performed for eligible Missouri Medicaid recipients, and for which Missouri Medicaid is to be billed, shall require a second surgical opinion by a licensed physician. Imposition of a second opinion requirement results from legislation passed by the 81st General Assembly of Missouri.
2. (2) The intent of the Second Surgical Opinion Program is to provide the eligible Missouri Medicaid patient with a second opinion as to the medical necessity of certain elective surgical operations. The surgical procedures of concern are those where there commonly may be a significant difference of opinion from one (1) physician to another. When the second opinion has been obtained, regardless of whether or not it confirms the primary recommendation for surgery, the final decision to undergo or forego elective surgery remains with the Medicaid patient.
3. (3) Elective surgical operations, as specified by the Division of Family Services and all costs directly related to elective surgical operations, shall require a second surgical opinion before the surgery is performed if Missouri Medicaid is to be billed for the surgical operation and related costs.
4. (4) The Division of Family Services reserves the right to revise, either by deletion or expansion, those elective surgical operations specified for the purpose of the second opinion requirement at any time a revision shall be necessary.
5. (5) Surgical operations and any costs related directly to those surgical operations which are not normally covered by Missouri Medicaid shall not be allowed for reimbursement under the Second Surgical Opinion Program.
6. (6) A second opinion shall be required for those elective surgical operations specified by the Division of Family Services, regardless of the setting in which the surgery is performed, unless an emergency situation exists.
7. (7) For the purpose of the second opinion requirement, nonemergency, elective surgical operations shall be defined as those where the patient’s life will not be threatened or the patient’s health will not be permanently impaired by any delay in performing the surgery.
8. (8) When the eligible Medicaid patient has obtained a proper second surgical opinion, regardless of whether or not it confirms the primary recommendation for the specific surgery, the final decision to undergo or forego the surgery shall remain with the patient.
9. (9) A third surgical opinion, provided by a third physician, shall be allowed by Missouri Medicaid if the second opinion fails to confirm the primary recommendation that there is medical need for the specific surgical operation and if the eligible Medicaid patient desires the third opinion.
10. (10) If a third surgical opinion is obtained, whether it confirms either the primary or secondary opinion, the final decision to undergo or forego the specific surgery shall remain with the eligible Medicaid patient. Medicaid will not cover a further opinion.
11. (11) A second opinion must be obtained within thirty (30) days after the primary recommendation. A third opinion must be obtained within thirty (30) days after the second opinion. The specific surgical operation under consideration must be performed within one hundred twenty (120) days after the primary recommendation.
12. (12) Each physician who provides a surgical opinion, the physician who performs the specific surgery and the hospital or other facility which provides directly related services must be enrolled in the Missouri Medicaid program if that provider desires to file a claim for Medicaid payment.
13. (13) Provider enrollment in the Missouri Medicaid program shall be as defined by the Division of Family Services and as permitted by enacted legislation. The division stipulates that reimbursement shall not be made for the services of staff-in-residence (for example, interns and residents).
14. (14) A physician providing a surgical opinion is not required to be either board-eligible or board-certified. However, the Medicaid patient shall be encouraged to seek a surgical opinion from a specialist in the appropriate medical field, wherever possible. 13 CSR 70-3
15. (15) The second (or third) opinion may be provided by a physician associated with the same medical practice as the primary physician, although the Medicaid patient shall be encouraged to seek the second (or third) opinion from a physician not associated with the same practice.
16. (16) When a second (or third) opinion has been obtained by the Medicaid patient, any one (1) of the Medicaid-participating physicians involved in the case may perform the specific surgical operation; or the case shall be closed at the end of the one hundred twenty (120)-day limit for that case.
17. (17) The physicians involved in the case may know each other’s identity(ies). No attempt shall be made by Missouri Medicaid to suppress this knowledge. Cooperation between the physicians is encouraged for the benefit of the Medicaid patient.
18. (18) The use of existing laboratory data, X rays, by the second (or third) opinion physician is necessary in every case where it is possible to form an intelligent surgical opinion based upon the existing diagnostic materials.
19. (19) To receive Medicaid reimbursement, the physician performing one (1) of the specified surgeries and the hospital or other facility providing direct patient care for the surgery shall attach a Missouri Medicaid second opinion form to the claim. The second opinion form must be properly completed by the attending physician, the physician(s) providing the second (and third) opinion(s) and the surgeon. It is the surgeon’s responsibility to furnish the hospital or ambulatory surgical center with a copy of the completed second opinion form.
20. (20) Anesthesiologists, assistant surgeons, independent laboratories, independent X-ray services, shall be exempted from attaching a second opinion form to their Medicaid claims relating to the specified surgical operations.
21. (21) The claims shall be denied if a Missouri Medicaid second opinion form is not attached, if the second opinion form attached is incomplete, illegible or not properly signed.
22. (22) All other rules and policies which are in effect for the Missouri Title XIX Medicaid Program shall apply to services provided under this rule. AUTHORITY: section 207.020, RSMo Supp. 1993.* This rule was previously filed as 13 CSR 40-81.052. Emergency rule filed Sept. 18, 1981, effective Sept. 28, 1981, expired Jan. 13, 1982. Original rule filed Sept. 18, 1981, effective Jan. 14, 1982.

*Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993. and Procedure of General Applicability 13 CSR 70-3