Surgery

The spending authority for surgery/surgeries for the life of the case is $10,000.

When an individual surgery or a combination of surgeries is projected to cost $10,001 or more, prior approval is required. Each RS Program Administrator will establish a procedure for routing such exception requests through the RS Managers, RS Program Administrator or both. Use of the Exceptions Request Form (see Section 8 / Part 54) is required. These costs include hospital and primary doctor fees. These costs do not include radiology, anesthesia or other related expenses.

When including surgery as an IPE service, regardless of the projected costs, the counselor must analyze and document the following factors:

• Prognosis and doctor’s written recommendation.
• Medical necessity.
• Analysis of whether there are feasible alternatives.
• Client’s prior efforts to resolve the issue using alternatives to surgery, if such alternatives are available and medically feasible.
• Client’s willingness to adhere to lifestyle changes, as appropriate, before and after surgery.
• Analysis of how the surgery will correct, stabilize, or reduce the progression of the disabling condition, if appropriate.
• Analysis of how/why the surgery is required to reduce or minimize an impediment to employment and the impact of this service on the client’s ability to achieve employment.
• Availability and application of comparable benefits (unless the client requires the service immediately because of extreme medical risk.)

Appropriate CPT and service codes are required.

Special procedures for dental surgery:

• The surgery analysis described above is required for oral and maxillofacial surgeries with American Dental Association (ADA) procedure codes D7260 to D7999.
• The surgery analysis is NOT required for ADA procedure codes D7000 to D7259. Therefore, most extractions will not require completion of the surgery analysis.
• The Counselor must get the ADA code from the dentist prior to authorizing the service in order to determine whether the surgery analysis is required.
• See Resources - Part 29 for a copy of the ADA code listing.

Effective Date: April 10, 2006