Page:United States Statutes at Large Volume 100 Part 1.djvu/233

 PUBLIC LAW 99-272—APR. 7, 1986

100 STAT. 197

"(2) SELECTION GUIDELINES.—

"(A) IN GENERAL.—The specification of procedures shall be consistent with selection guidelines established by the Secretary under paragraph (3). The procedures specified shall be included among the surgical procedures which the Secretary has identified as reasonably being able to meet such guidelines. "(B) EXCEPTION.—The Secretary may permit an organization to include among the procedures specified under paragraph (1) procedures not identified by the Secretary under paragraph (2)(A) if to do so would be cost effective and consistent with the criteria described in paragraph (3). "(3) CRITERIA.—The Secretary shall establish such guidelines and identify such surgical procedures consistent with the following criteria: "(A) The procedure is one which generally can be postponed without undue risk to the patient. "(B) The procedure is a high volume procedure among patients who are covered under the programs established under title XVIII or is a high cost procedure. 42 USC 1395. "(C) The procedure has a comparatively high rate of nonconflrmation upon examination by another qualified physician, there is substantial geographic variation in the rates of performance of the procedure, or there are other reasons why pre-procedure review for 100 percent of the procedures would be cost effective. "(4) QUALIFICATIONS OPINIONS.—

FOR PHYSICIANS

PROVIDING

SECOND

"(A) IN GENERAL.—The Secretary shall specify, for each procedure identified under paragraphs (2) and (3), the type or types of board certified or board eligible specialists who may conduct a second opinion, required under subsection (c), based upon the nature of the procedure. "(B)

FREEDOM OF CHOICE OF PATIENT TO CHOOSE PHYSI-

CIAN.—Subject to paragraphs (C) and (D), the patient may choose any physician of the proper specialty under subparagraph (A) to provide the second opinion. "(C) PHYSICIANS PROHIBITED FROM PROVIDING SECOND OPIN-

IONS.—For purposes of this section, a second opinion may not be provided by a physician who is affiliated with, or has a common financial interest with, the physician who rendered the first opinion that the procedure was necessary. "(D) RESTRICTED LIST.—In accordance with guidelines of the Secretary, an organization may disqualify a physician from providing a second opinion under this section because of the gross unreliability of the second opinions provided. '(c) REQUIRING A SECOND OPINION IN CERTAIN CASES.— "(1) DETERMINATIONS BY ORGANIZATION.—In the case of a

review performed pursuant to subsection (a), the organization shall determine, based on such review, that the surgical procedure— "(A) is reasonable and medically necessary, "(B) is not reasonable and medically necessary, or "(C) may be considered reasonable and necessary, but, because of questions as to the medical appropriateness of performing the procedure, it is appropriate to require the patient to seek a second opinion as to the necessity and

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