Necessary surgery is a term that refers both to a medical requirement for the surgery determined by a physician and to an insurance plan’s inclusion of the surgery in the covered conditions. For the most part, these two ways of talking about required surgery coincide. When they do not, the physician is asked to demonstrate to the insurance plan that the surgery is necessary by reference to the medical condition to be treated and the customary medical practice that deems it required as opposed to optional or elective.
Not all surgery is an emergency. Not all surgery is medically required. Some surgeries are for cosmetic or for aesthetic enhancements and are deemed optional or elective, both by physicians and by insurance plans.
Necessary surgery refers to surgical procedures that pertain to a condition that cannot be treated by other methods and, if left untreated, would threaten the life of the patient, fail to repair or improve a body function, increase the patient’s pain, or prevent the diagnosis of a serious or painful condition. The emphasis here is that, according to medical judgment, surgery is mandated.
Not all necessary surgery is absolutely required until the patient is satisfied that he or she has all the information needed to opt for surgery. All surgery has risks and the decision to have surgery is one that needs to be made by both the physician and the patient.
The decision to have surgery should be made by the patient after:
- complete evaluation by a physician to determine if the surgery is medically indicated
- discussion with the physician about alternative treatments
- discussion that allows the patient to understand why the surgery is necessary, what the surgery involves, and why the particular procedure has been chosen by the surgeon
- discussion of the complete risks and benefits of the procedure
- second opinion has been enlisted about the surgery and its components and/or alternatives (Many health insurance plans require this step and will pay for the second opinion.)
Only after a physician has taken the condition and symptoms into account with a complete evaluation of alternatives, will surgery be judged to be necessary. During the course of this evaluation, and after non-surgical treatments have failed, the patient needs to be actively involved in understanding the actual procedure that might mitigate the condition, the full array of risks and benefits of the surgery, and why the surgeon has arrived at the particular procedure. The patient should understand the likelihood of danger or risk if he or she foregoes the surgery and the patient needs to understand that there may be a possibility of improvement, given sufficient time, without the surgery. Before choosing to undergo a particular surgical procedure, the patient should get a second opinion about the wisdom, efficacy, risk, and benefits of the procedure.
Preparation for surgery should include knowing:
Alternatives to surgery— Other treatments for the condition or illness that do not involve surgery; these are usually tried before surgery is an option.
Elective surgery— Surgery chosen by someone over 18 and/or a guardian for a patient that is not medically required for an illness, condition, or pain relief.
Surgical alternatives— Surgical options within a range of surgical procedures used to treat a specific condition.
- Where surgery will take place and the length of stay in the hospital. Some insurance companies may press for shorter hospital stays.
- What pain medication will be used, and how medications for home use will be ordered for discharge. The physician should know all medications that are currently being taken.
- Who will make decisions on the patient’s behalf and with what legal authority, should the patient be unable to make a decision in the hospital. The physician and the nursing team need to know who this “patient advocate” is.
- What the visiting hours, rules, and limits on children are.
- That the hospital plans to accommodate any dietary restrictions the patient may have.
- That there is sufficient at-home assistance and resources for the patient upon discharge.
- The dietary and behavioral requirements for the days just preceding surgery.
Khatri, VP and JA Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.
Townsend, CM et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.
Patient Rights and Responsibilities. Agency for Health Care Research and Quality. http://www.consumer.gov/qualityhealth/rights.htm/.
Questions To Ask Your Doctor Before You Have Surgery. Agency for Health Care Research and Quality. http://www.ahcpr.gov/consumer/surgery.htm#head2/.
Wax, C. M. “Preparation for Surgery.” <http://www/HealthIsNumberOne.com>.
Nancy McKenzie, PhD