CurrentIndependent HealthPolicy M980101172

Cancer Diagnosis/Second Opinion

Policy governing coverage and requirements for obtaining a second medical or surgical opinion for cancer diagnosis, recurrence, or recommended cancer treatment for Independent Health members across specified lines of business.

Policy Summary

PayerIndependent Health

PolicyCancer Diagnosis/Second Opinion

Policy CodePolicy M980101172

Change TypeNo material changes

Effective Date1/1/1998

Next Review Date

Key ActionObtain preauthorization for out-of-network second opinion referrals when no qualified in-network physician exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple productsApplies to

office visit onlyCoverage scope

allowedThird opinion

requiredOON preauth

Second Opinion Coverage Criteria

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Root: Member meets indication AND product-specific conditions

Indication: One or more of: a positive or negative diagnosis of cancer; a recurrence of cancer; a recommendation of a course of treatment for cancer

Supported by clinical situations list

Product-specific condition

Commercial / Self-Funded / Child Health Plus / Essential Plan: Request is for a second opinion from a non-participating specialist and the attending physician provides a written referral to the non-participating specialist OR request is for a third oncological opinion when the first two opinions do not agree as determined by the Medical Director
Coverage limited to office visit; bring medical records; diagnostic testing not included unless preapproved
Medicare Advantage / MediSource / MediSource Connect: Request is for a non‑participating physician AND there is not an appropriate participating (in‑network) provider available
Preauthorization required for out-of-network referrals when no qualified in-network physician exists

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required for OON Second Opinions

Preauthorization is required for out-of-network referrals when Independent Health has determined there is no qualified in-network physician. All PPO members with out-of-network coverage do not have to obtain pre-authorization.

Preauthorization required when no qualified in-network physician is available
PPO members with out-of-network coverage are exempt from preauthorization

Documentation Required

Required Documentation for Second Opinion Visit

Members are instructed to bring complete prior medical records to the second opinion visit, including diagnostic reports, pathology reports, and previous in-plan consultation reports. Diagnostic testing is not included in the second opinion consultation unless previously approved by Independent Health's Office of the Medical Director.

Medical records
Diagnostic reports
Pathology reports
Previous in-plan consultation reports
Diagnostic testing only if previously approved by the Office of the Medical Director

Note

Third Opinion Process

If the first two oncologic opinions do not agree, coverage may be provided for a third oncological opinion in accordance with the same criteria. The determination that the first two opinions do not agree is made by the Medical Director.

Third opinion covered when first two opinions disagree
Medical Director determines whether opinions disagree
Third opinion follows same coverage criteria as prior opinions

Denial Risk

Coverage and Preauthorization Triggers

Independent Health provides coverage for a second opinion for a diagnosis of cancer by an appropriate specialist. Coverage is limited to an office visit only. For non-participating specialists, coverage is available when the attending physician provides a written referral; cost to the member is no greater than for an appropriate participating specialist. If there is no attending physician referral and the member's contract is in-network only, the member does not have coverage. If the member seeks a second opinion without a written referral for a diagnosis of cancer, out-of-network coverage is subject to applicable deductibles and coinsurance.

Second opinion coverage limited to office visit only
Non-participating specialist allowed with written attending physician referral
No coverage without attending physician referral for in-network-only contracts
Out-of-network deductibles and coinsurance apply when referral absent

Policy Background

A second medical or surgical opinion is a one-time evaluation by a second physician or specialist to review a diagnosis or a recommended course of treatment for cancer. Typical reasons to request a second opinion include uncertainty about diagnosis or stage, rare or unusual malignancies, differing treatment options, or when the initial physician is not a specialist in the relevant cancer type. Members seeking a second opinion should bring relevant medical records to the visit, including diagnostic and pathology reports and prior in-plan consultation reports.

Key Definitions

Attending physician — responsibilities

DefinitionAttending physician: the physician selected by or assigned to a patient who has primary responsibility for the treatment and care of the patient.

QualificationFor this policy, may also include a licensed, board certified, or board eligible physician qualified to practice in the specialty area appropriate to treat the insured for the service.

ScopeHas primary responsibility for the treatment and care of the patient under this policy.

Referral — second opinion to non-participating or specialty providers

DefinitionReferral: a written request for an authorization for a second opinion for the diagnosis of cancer to a non-participating provider or specialist.

PurposeUsed to request authorization for a non-participating provider or specialist to provide a second opinion for cancer diagnosis.

FormatMust be a written request as specified in this policy.