California Health and Safety Code 1367.63 – (a) Every health care service plan contract, except a …
(a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in subparagraph (A) or (B) of paragraph (1) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.
Terms Used In California Health and Safety Code 1367.63
- Contract: A legal written agreement that becomes binding when signed.
- department: means State Department of Health Services. See California Health and Safety Code 20
- Enrollee: means a person who is enrolled in a plan and who is a recipient of services from the plan. See California Health and Safety Code 1345
- licensed: refers to , a license as a plan pursuant to Section 1353. See California Health and Safety Code 1345
- plan: refers to health care service plans and specialized health care service plans. See California Health and Safety Code 1345
- specialized health care service plan: means either of the following:
California Health and Safety Code 1345
- State: means the State of California, unless applied to the different parts of the United States. See California Health and Safety Code 23
(c) (1) “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(A) To improve function.
(B) To create a normal appearance, to the extent possible.
(2) As of July 1, 2010, “reconstructive surgery” shall include medically necessary dental or orthodontic services that are an integral part of reconstructive surgery, as defined in paragraph (1), for cleft palate procedures.
(3) For purposes of this section, “cleft palate” means a condition that may include cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate.
(d) “Cosmetic surgery” means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Care Services.
(f) As applied to services described in paragraph (2) of subdivision (c) only, this section shall not apply to Medi-Cal managed care plans that contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) of, Chapter 8 (commencing with Section 14200) of, or Chapter 8.75 (commencing with Section 14591) of, Part 3 of Division 9 of the Welfare and Institutions Code, where such contracts do not provide coverage for California Children’s Services (CCS) or dental services.
(Amended by Stats. 2011, Ch. 367, Sec. 3. (AB 574) Effective January 1, 2012.)