Section 1367.635 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.635
. (a) Every health care service plan contract that is
issued, amended, renewed, or delivered on or after January 1, 1999,
that provides coverage for surgical procedures known as mastectomies
and lymph node dissections, shall do all of the following:
(1) Allow the length of a hospital stay associated with those
procedures to be determined by the attending physician and surgeon in
consultation with the patient, postsurgery, consistent with sound
clinical principles and processes. No health care service plan shall
require a treating physician and surgeon to receive prior approval
from the plan in determining the length of hospital stay following
those procedures.
(2) Cover prosthetic devices or reconstructive surgery, including
devices or surgery to restore and achieve symmetry for the patient
incident to the mastectomy. Coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and
coinsurance conditions applicable to other benefits.
(3) Cover all complications from a mastectomy, including
lymphedema.
(b) As used in this section, all of the following definitions
apply:
(1) "Coverage for prosthetic devices or reconstructive surgery"
means any initial and subsequent reconstructive surgeries or
prosthetic devices, and followup care deemed necessary by the
attending physician and surgeon.
(2) "Prosthetic devices" means and includes the provision of
initial and subsequent prosthetic devices pursuant to an order of the
patient's physician and surgeon.
(3) "Mastectomy" means the removal of all or part of the breast
for medically necessary reasons, as determined by a licensed
physician and surgeon. Partial removal of a breast includes, but is
not limited to, lumpectomy, which includes surgical removal of the
tumor with clear margins.
(4) "To restore and achieve symmetry" means that, in addition to
coverage of prosthetic devices and reconstructive surgery for the
diseased breast on which the mastectomy was performed, prosthetic
devices and reconstructive surgery for a healthy breast is also
covered if, in the opinion of the attending physician and surgeon,
this surgery is necessary to achieve normal symmetrical appearance.
(c) No individual, other than a licensed physician and surgeon
competent to evaluate the specific clinical issues involved in the
care requested, may deny requests for authorization of health care
services pursuant to this section.
(d) No health care service plan shall do any of the following in
providing the coverage described in subdivision (a):
(1) Reduce or limit the reimbursement of the attending provider
for providing care to an individual enrollee or subscriber in
accordance with the coverage requirements.
(2) Provide monetary or other incentives to an attending provider
to induce the provider to provide care to an individual enrollee or
subscriber in a manner inconsistent with the coverage requirements.
(3) Provide monetary payments or rebates to an individual enrollee
or subscriber to encourage acceptance of less than the coverage
requirements.
(e) On or after July 1, 1999, every health care service plan shall
include notice of the coverage required by this section in the plan'
s evidence of coverage.
(f) Nothing in this section shall be construed to limit
retrospective utilization review and quality assurance activities by
the plan.