MUTUAL BENEFIT HEALTH & ACCIDENT ASSOCIATION OMAHA

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP68-00140R000200180011-9
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 46
• Document Creation Date: December 22, 2016
• Document Release Date: May 26, 2009
• Sequence Number: 11
• Publication Date: August 1, 1960
• Content Type: CONT

Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
GENERAL PROVISIONS
1. ELIGIBILITY. Each person within the classes shown in the Plan of Insurance and Application
shall become eligible for insurance as hereinafter provided.
All persons presently within the eligible classes shall be eligible for insurance hereunder on the effective
date of the policy, except as follows :
?y s ?
? ?
? ?
?? ??? a ???
Each person who comes within the eligible classes after the effective date of this p& ic3i s6all be t4igible
for insurance on the date on which such person has been within the eligible classes for a qualify Ag? period
of None
Persons who are eligible by reason of employment but who are not actively at work when they would
otherwise be eligible shall become eligible on the date of their return to active work.
2. EFFECTIVE DATE OF INDIVIDUAL INSURANCE. Each eligible person who imakes writ n application
Mirt
y-one nays
for insurance hereunder during the required qualifying period, if any, or within
from the date he becomes an eligible person, shall become a protected person on the date such
application is made.
Any eligible person who makes written application more than thirty-one days after the date he
becomes an eligible person or who applies for reinstatement of his insurance after it has been terminated
because of failure to make any agreed contribution when due shall be required to furnish, at his own expense,
evidence of insurability satisfactory to the Association and such insurance shall not become effective prior to
a date determined by the Association.
3. AMOUNTS OF COVERAGE. The amounts for which a protected person is covered under this policy shall
be those amounts applicable to his classification shown in the Plan of Insurance. If a protected person's classi-
fication changes, the am unts for which he is covered under this policy shall be adjusted to conform to his new
classification effective tt:e first day of the policy month following the date his classification
but only after the Association has been notified by the Policyholder of such change in classification as req lr9cs
under General Provision 10.
In the event of a change in classification or in the Plan of Insurance because of an increase or decrease
in benefits, a protected person who is not actively at work on the date a change i%Akqifn11rnec t sscover-
age would otherwise become effective shall not be entitled to such benefit change
to active work
4. TERMINATION OF INDIVIDUAL INSURANCE. The insurance of any protected person insured here-
under shall terminate on whichever of the following dates occurs first:
(a) the first day of the policy month following the date he ceases to be
within the classes of persons eligible for the insurance under this policy, or
(b) the date that any contribu-
tion required on the part of the protected person is due and unpaid, or
(c) the first day of the policy month following the date the Policyholder
receives notice from the protected person that his insurance is to be terminated, or
(d) the date this policy is discontinued, or
(e) the date the protected person enters the armed forces on full-time active duty.
Form 701 MGM Page 2
I Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
A person who is eligible for insurance because of employment shall cease to be within the classes of persons
eligible for insurance upon termination of employment. Termination of employment shall, for the purpose of this
insurance, be defined as cessation of active work by layoff, work stoppage, leave of absence, resignation, dis-
missal, being pensioned or retired or cessation of active work because of disability.
If a protected person ceases to be within the classes of eligible persons, his insurance shall terminate on the
date specified in the preceding paragraphs, except that upon payment of the premium for such protected person
by the Policyholder, he shall continue to be a protected person for an additional period Of six (6)
months in the event of leave of absence or disability.
If a protected person's insurance is terminated during a disability covered by this policy and the protected
person returns to active work at the end of the period of his disability, his insurance under the policy may be
reinstated as of the date of his return to work without evidence of insurability.
If, at the time of termination of insurance, the protected person is receiving benefits in accordance with the
provisions of this policy, such benefits shall continue to be paid for the balance of the period for which he would
otherwise have been entitled to such benefits.
5. CONTINUANCE OF POLICY. This Policy may be continued in force, in accordance with General Pro-
visions 6, 7 and 8 relating to payment of premiums, for a further term of one year upon the payment, prior to
the expiration of the grace period immediately following the anniversary date of the policy, of the premium for
the insurance so continued.
If at any time the number of persons insured hereunder shall be less than 25 , or less than (5%
of those eligible for insurance, the Association reserves the right to decline to continue this policy on the first
policy anniversary or on any premium due date thereafter.
6. EXPERIENCE RATING. On the first policy anniversary and upon each premium due date thereafter,
providing the then current premium rate has been in effect for at least twelve months, the Association shall
have the right to change the premium rates at which further premiums shall be computed, but no increase in
premiums shall be retroactive.
The Association may, as of any anniversary date of this policy, declare a retroactive rate refund for the
policy year just completed. Should a Policyholder qualify for such retroactive rate refund and should such
refund exceed the Policyholder's share of the premium, the excess shall be applied by the Policyholder for the
sole benefit of the protected persons.
7. Pt YM$NT OF PREMIUMS. The initial premium shall be due on the 1st day of Au uast
19 6Q, fql. he period ending on the 15th day of August , 19 60. Subsequent premiums shall
be payable.' bi-weekly in advance on theist and 15thday of each ,ionth thereafter during the
contin aiirt:;of this policy. The policy anniversaries are deemed to occur on the 1st day of August
of each year beginning in 19 b7; The premium due on the effective date hereof and on each subsequent due date
shall lee't1ie. sum of the individual premiums of each protected person determined according to his respective
benefits and his classification at the time the premium is due.
Afl p*remiums or installments thereof are payable to the Association at the Home Office of the Association
in OmNV,:Nebraska, on or before each premium due date. Premiums may be paid annually, semiannually,
quarterll,'monthly, or any other mode mutually agreeable at the Association's rates therefor. The payment of
any pi'eYi'l"rh or installment thereof shall not maintain the policy in force beyond the due date of the next pre-
mium 3:ft'tff4tallment, except to the extent hereinafter expressly provided. The Association operates on the full
legal reserve basis and the contingent mutual liability hereunder shall not exceed one additional premium in the
amount?ef tke premium required herefor.
8. GRAIN PAYMENT OF PREMIUMS-TERMINATION OF POLICY. A grace period of thirty-one
days will be granted to the Policyholder for the payment of every premium due after the initial premium dur-
ing which time this policy shall remain in force, unless the Policyholder or the Association shall have given
previous notice that the policy is to be terminated as of the due date of such premium in which event no grace
period will be allowed.
If such notice is not given and the premium is not paid before the expiration of the grace period, this
policy may be terminated by the Association by mailing to the Policyholder written notice stating when, not
less than five days thereafter, such termination shall be effective. In the event of such notice, or if written notice
is given by the Policyholder to the Association during the grace period that the policy is to be terminated, the
Form 701 MGM Page 3
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
Policyholder shall be liable to the Association for the pro rata premium for the period from the due date of such
premium to the date of such termination.
The mailing of notice as aforesaid shall be sufficient proof of notice and shall terminate the policy as of
the date stated in the notice. Delivery of such written notice whether by the Policyholder or the Association
shall be equivalent to mailing.
9. POLICY CONTRACT. This policy and the application therefor together with the individual applications,
if any, of the protected persons, constitute the entire contract between the parties hereto. No change or modi-
fication may be made nor the date of payment of any premium changed except by agreement in writing signed
by an officer of the Association, and the Association shall not be bound by any promise or representation affect-
ing thi's':dfitract made at any time by any person other than an officer of the Association. All statements made
by the P(i yholder and the protected persons shall be deemed representations and not warranties and no such
statement-shall avoid this policy unless it is contained in the written application therefor, a copy of which is
attached heir to.
.....?
10. RI tDS_INFORMATION TO BE FURNISHED. The Policyholder shall keep a record of the pro-
tected pei ins, containing the essential particulars of the insurance of each such person. The Policyholder shall
furnish ?mtx-fthly, on the Association's forms such information relating to new
because vf? changes in classification and termination of insurance as may be requireddbyethe Association to
properly administer this insurance. The Policyholder's books and records which may have a bearing on the
insuraneo.provided under this policy shall be open to the Association for inspection at any time during the pol-
icy period aid within one year after termination of the policy.
11. CLFR-[CDAL ERROR. If an eligible person made proper written application for insurance hereunder dur-
ing the?pepie)d specified in the first paragraph of General Provision 2 and also made the required contribution,
if any, to th-c Policyholder, but, through clerical error, the Policyholder failed to give due notice thereof to the
Association, the insurance to which such eligible person would have been entitled shall nevertheless be effec-
tive from the date specified in the first paragraph of General Provision 2 as soon as proper premium remittance
to the Association is made.
J2. INDIVIDUAL CERTIFICATE. The Association will issue to the Policyholder for delivery to each pro-
tected person insured hereunder an individual Certificate setting forth a statement as to the insurance benefits
to which such protected person is entitled under this policy and to whom such benefits are payable.
13. EXCLUSIONS AND LIMITATIONS. This policy does not cover (a) injuries arising out of or in the
course of the employment of the protected person or his dependents or sickness covered by a Workmen's Com-
pensation Act or similar legislation, (b) hospitalization or medical or surgical treatment provided by or paid for
by the United States Government or any instrumentality thereof, (c) any loss caused by war or act of war, or
(d) loss incurred while engaged in military, naval or air service.
Form 701 MGM Page 4
Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Effective Date August 1, 1960
Classification
Class 1 - All full time active employees of
Engineering Research.
Premiums
The bi-weekly premium for each protected person
is as follows:
Class 1 . . . . . . . . . . . . $1.57
Dependents . . . . . . . . . . $4.64
Form 702MGI Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9, an
 Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
DEPENDENT INSURANCE
ELIGIBILITY. The insurance specified herein on account of Dependents is applicable only if the
protected person is eligible for, has requested, and is insured for such dependent insurance.
Eligible dependents shall include the spouse of the protected person and the protected person's
unmarried children, excluding in any case:
(a) a child more than 18 years of age, except that unmarried children who are 18 but less than
23 years of age are eligible if they are wholly dependent upon the protected person for
support and maintenance and their time is devoted principally to attending school or college,
(b) the spouse of the protected person, if legally separated from the protected person, and
(c) any dependent who is eligible for insurance under the policy as a protected person.
If both husband and wife are insured under this policy as protected persons, children may be
insured as dependents of the husband or wife, but not both.
A protected person's children shall include any step-children, legally adopted children, and
foster children provided such children are dependent upon the protected person for support and
maintenance.
EFFECTIVE DATE OF DEPENDENT INSURANCE. If a protected person makes application for de-
pendent insurance in his original application for insurance (provided such application was made
during the required qualifying period, if any, or within thirty-one days from the date the protected
person became eligible for insurance under this policy), such dependent insurance shallbecome ef-
fective on the date the protected person's insurance becomes effective. If a protected person has no
eligible dependents on the date he becomes insured under this policy and subsequently acquires a
dependent and makes application for insurance for such dependent within thirty-one days thereafter,
such insurance for eligible dependent shall become effective on the date such application is made or
the date a protected person acquires an eligible dependent, whichever is later.
If written application for dependent insurance is made at any time other than that specified in
the preceding paragraph, or if a protected person applies for reinstatement of his dependent insur-
ance after it has been terminated because of failure to make any agreed contribution when due, the
protected person shall be required tp furnish, at his own expense, evidence satisfactoryto the As-
sociation of the insurability of each eligible dependent the protected person then has and such insur-
ance shall not become effective prior to a date determined by the Association.
If a protected person, after his dependent insurance becomes effective, acquires an additional
eligible dependent, the protected person shall be automatically insured with respect to such de-
pendent.unl,pss the premium rate applicable to the protected person's dependent insurance would
thereby.JcIO increased. If the premium rate would be increased, the protected person shall become
insure4.vWj,t4 respect to such additional eligible dependent only under the conditions stated in the two
prec edina,pf.ragraphs.
w.w..
If' d2p~ndent is confined in a hospital on the date such dependent becomes eligible or on the
date a c 4ge in coverage would otherwise become effective, the dependent's insurance or change
in cov(!rag~pwshall not become effective until final discharge from the hospital. This requirement,
howevai;.ws4all not apply to a new-born child confined in a hospital at birth.
TERMha'1 TION OF DEPENDENT INSURANCE. The insurance of any dependent insured hereunder
shall ter`r! nate on whichever of the following dates occurs first:
(a)"CYM~ first premium due date following the date such dependent ceases to be an eligible de-
"w'i3thdent, or
(b) this date the protected person's coverage hereunder terminates, or
(c)"I date the protected person fails to make the agreed contribution for dependent coverage,
wor
(c1)"lit date the dependent enters the Armed Forces on full-time active duty, or
(e) the date this policy is discontinued.
If at any time the number of protected persons insured with respect to all their eligible de-
pendents hereunder shall be less than 75 per cent of all eligible protected persons having dependents,
the Association reserves the right to decline to continue this dependent insurance on the first policy
anniversary or on any premium due date thereafter.
Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
If a protected person ceases to be within the class or classes of persons eligible for insurance
under this group policy, such protected person shall be entitled to have issued to him, without fur-
nishing evidence of insurability, an individual policy, or, if the protected person's dependents were
also insured under this group policy, a family policy; provided that such protected person is then
under 76 years of age and makes written application and the first premium payment therefor to the
Association within thirty days after termination of his insurance under this group policy. The form
of the individual or family policy, the coverage thereunder, and all other terms and conditions
thereof shall be as provided by the rules of the Association for such individual or family policy at the
time of such application. Under the family policy the protected person may include only those of his
dependents, excluding any dependent children over age 17, who were insured under this group policy
on the date his insurance terminated.
The individual or family policy, if issued, shall become effective on the day the application is
signed or on the date of termination of insurance under this group policy, whichever is the later,
and any benefits which are payable under this group policy shall be excluded from coverage under
the individual or family policy.
If a protected person, after converting to an individual or family policy, again becomes eligible
for insurance under this group policy and his individual or family policy is continued in force after
he again becomes eligible, such person shall be required to furnish, at his own expense, evidence
of insurability before he may again become insured under this group policy. In the event a protected
person has a family policy which is continued in force after he again becomes eligible for insurance
under this group policy, such protected person shall also be required to furnish, at his own expense,
evidence of insurability for each of his dependents before they may again become insured as de-
pendents under this group policy.
Regardless of any provision contained in this conversion privilege, the issuance of any policy
described herein shall be subject to all of the rules and regulations of the state in which application
is made.
? ?
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
The benefits for dependents provided herein shall be applicable only if the protected person is eligible for,
has requested and is insured for such dependent benefits.
If a protected person or dependent is eligible for benefits under any other group policy issued by the As-
sociation, the amount payable under this policy shall be reduced by the amount payable under such other
group policy.
PART A.
HOSPITAL EXPENSE BENEFITS
HOSPITAL ROOM BENEFIT. If a protected person or an eligible dependent, because of accidental bodily
injuries or sickness, shall be confined as a resident patient in a hospital,' the Association, provided such
hospital confinement commences while the protected person or dependent is insured under this policy, will
pay benefits for, the expense actually incurred by the protected person for hospital room and board during
the period of hospital confinement, but not to exceed $20. 00 per day nor to exceed 90 days for any one
period of hospital confinement.
MISCELLANEOUS HOSPITAL EXPENSE BENEFITS. During the period of hospital confinement for which
benefits are paid under the preceding paragraph, the Association will pay for the expense actually in-
curred by the protected person for all other necessary care and treatment for which the hospital makes a
charge (excluding charges made by the protected person's or dependent's nurse or physician) togetherwith
the expense actually incurred for regular and customary charges made by' the ambulance company for
transportation to and from the hospital in an ambulance (up to $25.00 for any one period of hospital con-
finement), but not to exceed 1007 of the first $202. 50 of covered miscellaneous hospital expenses plus
80% of the balance, and not to exceed, in the aggregate, $5, 000. 00 for all such expense incurred for any
one period of hospital confinement.
OUTPATIENT SERVICE IN A RECOGNIZED HOSPITAL OR CLINIC. If a protected person or an eligible
dependent shall, while insured under this policy and because of accidental injuries or sickness, receive
outpatient services in a hospital or clinic listed by the American Hospital Association in their Guide Issue,
the Association, providing no benefits are payable under any other provision of this policy, will pay for
the expense actually incurred for such service of the type described in the policy under MISCELLANEOUS
HOSPITAL EXPENSE BENEFITS, but not to exceed, in the aggregate, $202. 50 for any one accident or
sickness.
SUCCESSIVE PERIODS OF HOSPITAL CONFINEMENT. Successive periods of hospital confinement shall
be considered one period of hospital confinement unless:
(1) In the case of a protected person, the subsequent confinement commences after return to active
work on full time or unless the subsequent confinement is due to causes entirely unrelated to the
causes of the previous confinement, or
(2) In the case of a dependent, the subsequent confinement commences more than three months after
the previous confinement or unless the subsequent confinement is due to causes entirely unrelated
to the causes of the previous confinement.
MATERNITY BENEFITS. If a female protected person or a dependent wife, while insured under this
policy, shall become confined in a hospital as a result of pregnancy, including resulting childbirth or mis-
carriage, the Association will pay benefits up to $16. 00 per day during the period of hospital confinement,
but not to exceed 8 days for any one pregnancy, except that for a cesarean section or miscarriage, the
Association will pay for the expense actually incurred during the period of hospital confinementforhospi-
tal care, treatment and service (of the type described under HOSPITAL ROOM BENEFIT and MISCEL-
LANEOUS HOSPITAL EXPENSE BENEFITS) received by the female protected person or dependent wife in
her own behalf, but not to exceed, for any one pregnancy, the limits specified for any one period of hospi-
tal confinement under HOSPITAL ROOM BENEFIT and MISCEL LANEOUS HOSPITAL EXPENSE BENEFITS.
Moreover, any bassinet or nursery charges made by the hospital for any day on which both mother and
child are jointly confined in the hospital shall be deemed to be expenses attributable to the mother -onlyand
shall not be Covered Charges of the child for any purpose under this policy.
In case the female protected person or dependent wife is not hospital confined at any time during preg-
nancy, but is cared for at home by a registered graduate nurse, the Association, provided maternity bene-
fits wveal~l?ha.ve beennp2~y ble if tlse protected person or dependent wife was hospital confined, will pay for
the exQeasa, a7?tua~y iaxurre&fqtr suuhoijjxse's fees, but not to exceed $36. 00 for any one pregnancy.
Mat&j ity ber af.ts for ~e nale;p6teated persons are not payable unless covered under a family enrollment.
EXCEPTION. This HOSPITAL EXPENSE BENEFITS provision does not cover pregnancy, including re-
sulting childbirth or miscarriage, except as provided under MATERNITY BENEFITS. This provision is also
subject to the EXCLUSIONS AND LIMITATIONS section of the General Provisions.
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
INTEGUMENTARY SYSTEM
PART B.
SURGICAL OPERATION EXPENSE BENEFITS
If a protected person or an eligible dependent, while insured under this policy, shall, because of accidental
bodily injuries or s icknes s, have an operation performed or a dis location or fracture repaired by a physician
or surgeon, the Association will pay for the expense actually incurred therefor, but not to exceed that amount
which results when the particular Surgical and Anesthesia Relative Value Units listed in the following
Schedule for the surgical procedure performed is multiplied by the Unit Value of $5. 00.
Skin and Subcutaneous Areolar Tissue
Relative
Value
Units
Incision Surg. Anes.
*0101 Drainage of infected steatoma .. 1.0
*0102 Drainage of furuncle . .... . . 1.0
*0108 Drainage of carbuncle ....... 1.0
*0114 Drainage of subcutaneous abscess
(where not specified elsewhere). 1.0
*0115 Drainage of pilonidal cyst . . . . 1.0
*0125 Drainage of onychia or parony-
chia, with or without complete
or partial evulsion of nail..... 1.0
*0130 Incision and removal of foreign
body, subcutaneous tissues,
simple ................ 2.0
*0140 Drainage of hematoma f ...... 1.0
*0145 Puncture aspiration of abscess
or hematoma ............. 1.0
Excision
0171 Biopsy of skin or subcutaneous
tissue ......... ... 2.0
0178 Excision of small neoplastic,
cicatricial, inflammatory or
congenital lesion of skin or
subcutaneous tissues, one .... 3.0 T
0180 more than one ........... 4.0 4.0
0190 Wide excision of lesion of skin
or subcutaneous tissues, one .. 5.0 T
0191 with graft or plastic closure
(see 0260 to 0325)
0215 Lipectomy (see 0178 to 0190,
0260 to 0262)
*0230 Excision of nail, nail bed or
nail fold, partial ........... 2.0
0231 complete .............. 5.0 T
0238 Exc ion of pilonidal cyst or
sinus ......20.0 7.0
0240 Excision of hidradenitis
suppurativa (see 0178 to
0190, 0260 to 0319)
0242 Excision of post-phlebitic
varicose ulcer with graft
(in. p djesj(t?p rocedure) l ~e~ r ? .
0298 is 03%) t ? ? .?? . :?
? ? ? ? ? ? ? ? ? ? ? ? .
SiMp113 see ? ? ? ? ?.? ? :
0251 Wounds, small, suture of
recent small wounds requiring
closure (up to 2 1/2 inches) ... 3.0 T
Form 785MGI
Repair - Simple (continued)
0253 Debridement, extensive
abraded wounds, skin (same
as 0351 to 0356) ........ .
Repair - Plastic Surgery
The following values (0260 to 0325)
are to be applied in situations where
delicate handling of tissues, meticulous
closure of wounds in layers, and other
time-consuming techniques commonly
employed by the plastic and recon-
structive surgeon are necessarily used
to obtain maximum functional and
cosmetic results. They include the
creation or preparation of the defect and
its repair. The measurements listed
refer to the size of the surface defect.
A copy of the operative note including
operating time must be supplied upon
request.
The values listed are for procedures
carried out on the trunk area. Values
for the same procedures carried out
elsewhere on the body where greater
degrees of skill, effort and time are
necessary are calculated by multiplying
the listed base values by the appropriate
following factor:
(a) Scalp, arms, legs ........ one and one-half
(b) forehead, cheeks, shin,
mouth, neck, axilla,
times base value
genitalia, hands, feet ... two times base value
(c) eyelids, nose, ears,
lips (except V-exci-
sions - items 2742 to
2743) ................. two and one-half
0260 Excision and/or repair by times base value
direct closure of essentially
round neoplastic, cicatricial,.
inflammatory, traumatic or
congenital lesions creatinga
surface defect up to 1 /8 inch
i
d
n
iameter ......... ..
3.0 T
0261
1/8 inch to 3/8 inch in
diameter
7.0 T
0262
over 3/8 inch in diameter
15.0 T
0265 Ex
cision and/or re ai b
p
r
y
direct closure of linear
lesion or wound creatinga
surface defect up to 1/8
inch wide and 3/4 inch long
Surg. Anes.
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Repair - Plastic Surgery (continued)
0266 each additional 1/2 inch . . . .
0275 Excision and/or repair by
Z-plasty, rotation flap,
advanced flap, double pedicle
flap, or other rearrangement
and suturing of adjacent
tissues, small .... ......
0276 large.. ..... , . , , , , ,
GRAFTS - List dimensions of defect
covered, location of defect and type of
graft. Fee includes creation or surgical
preparation of defect, the obtaining and
placing of the graft and the care of the
donor site (except in items 0297 and
0309).
*0288
0289
0291
0295
0296
0297 requiring skin graft of local
flaps to repair donor site
(use multiple procedure
formula to obtain value of
donor site repair)
0308 direct flap or tube pedicle for-
mation, initial stage ........ 20.0 6. 0
0309 requiring skin graft to re-
pair pedicle flap donor site
(use multiple procedure
formula to obtain value of
this donor site repair)
0310 delay, intermediate transfer,
or sectioning of pedicle of
tube or flap graft .......... 15.0 4. 0
0311 excision of lesion or prepara-
tion of recipient site and attach-
ment of tube or pedicle graft.. . 20.0 T
BURNS- iisUperoeutapeoib4dys rlaoe
involved,. loQafaA.of involved araa.age . .
of patient,. and d4sre? cd leurn.
(Does not include kingrafts.) . . ,
*0352 Dressings, initial or subsequent
under anesthesia, small ..... 4. 0 T
Form 785MGI
Surg. Anes.
BURNS - continued
1.0 T
*0353
under anesthesia, large or
with major debridement,
per hour .. . .. . . . .. . .
Destruction
*0401
Cauterization or fulguration
15.0
T
of local lesion, single
small
25.0
T
,
,
initial ...............
*0402
subsequent ...........
Skin grafts, pinch or split skin,
less than 2 square inches .. 5.0
T
pinch or split skin, 2 to 32
square inches ........... 20.0
T
each additional 32 square
inches or part thereof at
same procedure ......... 10.0
T
free full thickness, up to 3
square inches .............
20.0
T
each additional 3 square
inches or part thereof at
same procedure ......... 10.0
T
Surg. Anes.
100.0 T
Incision
*0430 Puncture aspiration of cyst . 1.0
0431 Mastotomy with exploration,
or drainage of abscess - deep 10. 0 5.0
Excision
0441 Biopsy of breast ......... 10.0 5.0
0445 Excision of cyst, fibroade-
noma or other benign tumor,
aberrant breast tissue, duct
lesion or nipple (including
any other partial mastectomy),
unilateral .............. 15.0 5.0
0446 Excision of chest wall tumor
involving ribs .......... 70.0 15. 0
0447 Excision of chest, wall tumor
involving ribs plus plastic
reconstruction ......... 100.0 21. 0
0451 Excision of cyst, etc. ,
bilateral ..... ..... .. 25.0 7.0
0457 Complete (simple)
mastectomy ........... 30.0 8.0
0470 Radical mastectomy, includ-
ing breast, pectoral muscles
and axillary lymph nodes... 60.0 12.0
MUSCULOSKELETAL SYSTEM
BONES
These fees include the application of first
cast or traction device.
Incision
0501 Aspiration biopsy of bone
marrow, including sternal
puncture .......... ... 3.0
0506 Incision of soft tissue, abscess
from osteomyelitis ....... 10.0 4. 0
0513 Sequestrectomy for osteo-
myelitis or bone abscess,
superficial ............ 10.0 4. 0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
0516 Removal of metal band, plate,
screw or nail (independent
Surg. Anes.
0593 Insertion of metal pin
Surg. Anes,
procedure) ..............
OSTEOTOMY - Cutting, division or
transection of bone, with or without
internal fixation.
0526 Clavicle. . .
0527 Humerus .
0530 Radius (malunited Colles'
fracture) ............. . .
0531 Ulna .... ......... .
0532 Femur, subtrochanteric . . . .
0534 Femur, supracondylar......
0536 Tibia.......
0537 Lesser bones ............
0538 Correction of bowlegs or
knock-knees, bilateral ......
0539 unilateral .............
excision
0550 Biopsy bone, superficial.....
0551 deep ................
0552 Claviculectomy, partial.....
0553 total .....
1)554 Astragalectomy .... .....
1)556 Excision of head of radius . . .
;)557 Carpectomy, one bone ......
3560 Coccygectomy ...........
3561 Patellectomy or hemi-
patellectomy ............
3563 Metatarsectomy ..........
3565 Excision of bone marrow . . . .
3566 Excision of bone cyst, chon-
droma, or exostosis, large
b
ones ....
15.0
T
30.0
6. 0
35.0
6.0
30.0
6.0
30.0
6. 0
60.0
12.0
60.0
12.0
40.0
8.0
25.0
6.0
50.0
12.0
30.0
6. 0
4.0
4. 0
20.0
5.0
30.0
6.0
50.0
9.0
40.0
8.0
30.0
7. 0
25.0
7.0
30.0
7.0
35.0
7.0
20.0
6.0
4.0
......... . . . . 40.0 8.5
1567 small bones ..... 20.0 6. 0
1576 Partial ostectomy; partial
excision of bone; crateriza-
tion, guttering or sauceriza-
tion of bone.; diaphysectomy -
femur, tibia, humerus,
radius, fibula, etc. ....... 40.0 8.5
-577 lesser bones ........... 20.0 6.0
580 Radical resection of bone for
tumor with bone graft, major
bone. ............ 80.0 16.0
581 minors bow %. .... i s . 5.0. 0 ? 11.0
. . . .. . . . . . .. . . .
roduction 4ndepe~den~ p, oredulreoi3ly; . ?
- associated procedureb, seeFrattures}. ?
591 Insertion of wire (Kirschner
wire) ................. 5.0 4.0
- -
rm 785MG1
(Steinmann pin) ......... 5. 0 4. 0
0595 Insertion of caliper or tongs . 5. 0 4.0
0597 Insertion of threaded or
beaded wire ............ 5.0 4.0
Repair
0611 Osteoplasty: shortening of
bone, femur, tibia, humerus. 80.0 12.0
0612 shortening of bone, radius
ulna. , . ... . ' . . ' ' . 50.0 10.0
0613 other bones.. 30.0 8.5
0614 lengthening of bone ...... 100.0 18.0
0616 mandibular for prognathism
or micrognathism, one or
two stages............ 100.0 T
BONE GRAFT - Osteoperiosteal graft;
periosteal graft. Includes obtaining and
placing of graft.
0617 Bone graft; femur, tibia,
humerus ......... . . . . . 80.0 16.0
0618 radius, ulna . 50.0 11.0
0619 autogencus, to face or
skull (including taking
and plac.ir.'g)........ by report T
0620 other bones........... 30.0 9. 0
0622 Bone or cartilage graft, non-
autogenous, or heterologous
graft, to face or skull (in-
cluding preparing and placing
material) .............. 50.0 11.0
0634 ' Spinal fusion with partial ex-
cision of intervertebral disk
(see joints - Excision -
1075 to 1076) ........... 100.0 18.0
0635 Spinal fusion, more than two
segments . . . . 80.0 17.0
0642 Lumbosacral fusion.. 70.0 15.0
0645 Scapulopexy ............ 50.0 12.0
0648 Patellapexy ..... .... 40.0 9.0
0649 Pectus excavatum - infants
plastic repair ... 30.0 7. 0
0650 Pectus excavatum (major)
plastic repair .......... 100.0 17. 0
0654 Epiphyseal-diaphyseal fusion;
epiphyseal arrest; epiphysi-
odesis, femur .......... 40.0 9.0
0655 tibia and fibula ? . 40.'0 9.0
0656 combined (femur, tibiaand
fibula) .............. 60.0 12.0
0657 combined (upper and lower
tibial and fibular)....... 60.0 12.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
0667 Freeing of bone adhesions,
callus or synostosis (inde-
pendent.procedure)
(see Ostectomy)
Manipulation
*0681 Skull, nonoperative ........ 3.0
0683 depressed with operation... 50.0 13. 0
Facial Bones
0686 Nasal, simple, closed re-
duction ................ 5.0
0687 compound, closed reduction. 10.0 T
0688 simple or compound, open
reduction ............. 20.0 7. 0
0691 Malar, simple, closed reduc-
tion .................. 5.0
0693 Malar, simple or compound,
depressed, open reduction . . . 30.0 7. 0
0694 multiple surgical approaches 50. 0 11. 0
0696 Maxilla, simple, closed reduc-
tion .................. 5.0
0699 Maxilla, simple or compound,
closed reduction, with wiring
of teeth ...... ........ 30.0 9.5
0701 simple or compound, open
reduction, with wiring of
teeth or local fixation ..... 50.0 11.0
0702 multiple, simple or com-
pound, complicated, open
reduction, and fixation by
traction, head caps,
multiple internal fixation,
etc. ............... 100.0 19.0
0703 Mandible, simple, closed re-
duction ................ 5.0
0704 Mandible, simple or com-
pound, closed reduction and
wiring of teeth ........... 30.0 9. 0
0705 simple or compound, open
reduction ............. 50.0 11.0
0706 skeletal pinning with ex-
ternal fixation .......... 40.0 10.0
Spine and Trunk
0720 Vertebral body, closed reduc-
tion, one .. .. 20.0 T
0721 ..'Mote $11 4Ae.::...:.: *30.:) T
0732 SacrZ. 'i, Vom~ountl :. .. ;'. . ; 2%:) T
0740 C.l tv cle?,pinfgtt,:ctosec: rp . : :
duction ................ 10. 0 4.0
0741 compound ............. 20.0 4.0
Form 785MGI
Spine and Trunk (continued) Surg. Anes.
0742 simple or compound, open
reduction ............ 30.0 T
0747 Scapula, simple, closed re-
duction ............... 10.0 4.0
0752 plus acromial process,
simple, closed reduction.. 15.0 4.0
0753 compound ..... ... 30.0 7.0
0754 simple or compound,
open reduction ....... 45.0 9. 0
0756 Sternum, simple, nonde-
pressed, closed reduction .. 10.0 4.0
0757 com pound .. . . . ... . . . . 20.0 4.0
*0761 Ribs, simple, strapping.... 2.0
Pelvis (Ilium, Ischium, Pubis)
0767 Fracture, simple closed re-
duction ..... ......... 10.0 4.0
0770 one or more bones, com-
pound ... .. 40.0 8.0
0771 one or more bones, simple
or compound, open reduc-
tion ....... .... ... 60.0 13.0
0772 Acetabulum, with or without
other fractures of pelvis,
simple, closed reduction, no
displacement .. . ...... 20.0
0773 central, with displacement 40.0 7. 0
0774 compound . .... ..... 30.0 7.0
0775 simple or compound, open
reduction ............ 60.0 13. 0
Upper Extremity
0778 Humerus, surgical neck,
simple, not requiring manip-
ulation ............... 15.0
0780 surgical neck, simple, re-
quiring manipulation with
general anesthesia ..... 25.0 6. 0
0781 compound .......... 30.0 7.0
0782 simple or compound,
open reduction ........ 40.0 11.0
0784 shaft, simple, closed re-
duction ............. 15.0
0785 simple, closed reduction
with general anesthesia . 25.0 6.0
0787 simple or compound,
open reduction ....... 40.0 10. 0
0788 skeletal pinning with ex-
ternal fixation ........ 30.0 6. 0
0791 Elbow (distal end of humerus,
proximal end of radius,
proximal end of ulna), con-
dyle only, simple, closed re-
duction ............... 15.0 4.0
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Upper Extremity (continued) Surg. Anes.
0792 one or more bones, simple,
closed reduction ........ 15.0
0793 one or more bones, com-
pound ........... . 40.0
0794 one or more bones, simple
or compound, open reduc-
tion... .. .. .. 40.0
0795 skeletal pinning with exter-
nal fixation............ 30.0
0796 supracondylar.......... 20.0
0797, olecranon, open reduction... 30.0
0798 Radius, head; simple, closed
reduction . ... ....... . 10.0
0800 head, compound . , .. . 20.0
0801 simple or compound, open
reduction . , . .... 30.0
0802 shaft, simple, closed re-
duction, without displace-
ment .. 10.0
0803 simple, closed reduction,
with displacement...... 15.0
0804 compound ........... 20.0
0805 simple or compound, open
reduction ........... 30.0
0807 distal end, Colles'(including
ulnar styloid), simple,
closed reduction ........ 15.0
0810 simple or compound, open
reduction . . ..... 30.0
0811 skeletal pinning with external
fixation . .. . 20.0
0813 Ulna, shaft, simple, closed
reduction. . , . , . 10.0
0814 shaft, simple, closed reduc-
tion with displacement and
with general anesthesia. . . . 15.0
0815 compound ........... 20:0
0816 simple or compound, open
reduction ........... 30.0
0817 skeletal pinning with exter-
nal fixation.. , 25.0
0820 Radius and ulna, simple, closed
reduction . , 15.0
0821 simple, closed reductionwith
general anesthesia... ; ... 22.5
0823 simple or compound, open
reduction . .. ...... 45.0
1)824 skeletal pinning withexter-
tial-fixabion. *. ,. ? . t .-.-P 80.0.
. . . . . : . .
3827 Gtarparl >;ioMes, ~one,?s~rrxle, .. . ..? .
closes reduction, .0. i .. i .*.. .8.b*
7830 one, simple or compound,
open reduction.......... 25.0
arm 785W31
Upper Extremity (continued) Surg. Anes.
0842
Metacarpal, one, simple,
4.0
closed reduction..........
7.0
4.0
0844
one, simple or compound,
7.0
open reduction, ......... 20.0
7.0
0848
skeletal pinning with exter-
nal fixation ............ 20..0
7.0
10.0
0852
Phalanx or phalanges, one
finger, or thumb, simple,
6. 0
closed reduction ..........
5.0
4. 0
4.0
0853
one finger, or thumb, com-
8.0
pound ............. .. 5.0.
4,0
0854
simple or compound, open
4.0
reduction ........... 15.0
5.0
4.0
Lower Extremity
8.0
0865
Femur, neck, simple, closed
reduction, with fixation ..... 30.0
8.0
0867
neck, simple or compound,
4.0
open reduction .......... 60.0
12. 0
0868
multiple pinning, with or
4.0
without external fixation.. 60.0
12.0
4.0
0872
intertrochanteric, simple,,
closed reduction with fixa-
8.0
tion ......... .... 30.0
6. 0
0874
simple, open reduction ..60.0
12.0
0877
slipped epiphysis, closed
4. 0
reduction with fixation .... 30.0
6. 0
0878
open reduction, acute ... 60.0
12.0
8.0
0879
reconstructive, late ... 100.0
18.0
0881
shaft, including supra-
6.0
condylar, simple, closed
reduction ............ 30.0
6. 0
4.0
0882
Femur, compound with
general anesthesia ....... 40.0
9.0
0883
simple or compound,
5. 0
open reduction ....... 60.0
12.0
5.0
0884
skeletal pinning with ex-
ternal fixation........ 40.0
7.0
8.0
0885
Knee (distal end of femur,
proximal end of tibia,
6.0
proximal end of fibula),
femur or tibia, condyle -
closed reduction ......... 20.0
0886
compound with general
6.0
anesthesia ........... 30.0
7.0
0887
simple or compound, open
10.0
reduction ............ 40.0
11.0
0889
two condyles .......... 35.0
7.0
7. 0
0895
Patella, simple.......... 10.0
0896
compound with general
4.0
anesthesia ........... 20.0
5.0
0897
simple, open reduction ... 30.0
8.0
7.0
0901
Tibia, shaft, simple, closed
reduction .............. 15.0
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
wer Extremity (continued) Surg. Anes.
)02 with general anesthesia ... 22.5 6. 0
'904 simple or compound, open
reduction ............. 40.0 9.0
-907 malleolus, simple, closed
reduction ............. 15.0
910 simple or compound, open
reduction............ 30.0 8.0
914 Fibula, shaft, simple, closed
reduction .............. 10.0
916 simple or compound, open
reduction ............. 20.0 6. 0
+920 malleolus, simple, closed
reduction ............. 10.0
.922 simple or compound, open
reduction ........... 30.0 8.0
1926 Tibia and fibula, shafts, simple,
closed reduction ...... . . . . 20.0
7927 compound with general
anesthesia . . . 30.0 7.0
1928 simple or compound, open
reduction .. . . . . . . . .. 50.0 10.0
]930 skeletal pinning with exter-
nal fixation .. 40.0 7.0
]933 Ankle, bimalleolar (including
Pott's) simple, closed reduc-
tion ................... 20.0
3934 compound, with general
anesthesia ............ 30.0 6.0
3935 simple or compound, open
reduction............ 40.0 9. 0
3938 trimalleolar, simple, closed
reduction ............. 25.0
3940 compound, with general
anesthesia ..... .... 37.5 7.0
3941 simple or compound, open
reduction.......... 50.0 11.0
0944 Tarsal (except astragalus and
os calcis), one, simple, closed
reduction..... 8.0
[)945 one, compound, with general
anesthesia ............ 16.0 6.0
1)946 one, simple or compound,
open reduction.......... 24.0 8. 0
0955 Astragalus, simple, closed re-
duction ................ 15.0
0956 compound, with general
anesthesia ............ 22.5 6.0
0957 simple or compound, open
1Vttoll C ? e.~ ? y" . 0 8.0
0961 Os %al{, 1, ;imljle, Clcs .Pd 3e;? : ?.;
duFJiroij . ? 0
0962 compound, with general
anesthesia .... ? .. ? ? . ? . 22.5 6.0
worm 785MGI
-7-
Lower Extremity (continued) Surg. Anes.
0963 simple or compound, open
reduction ..... ? .... 45.0 8.0
0964 skeletal pinning with exter-
nal fixation ........... 30.0 6.0
0967 Metatarsal, simple, closed
reduction, one .......... 7.0
0968 one, compound, with general
anesthesia ........... 14.0 6.0
0970 one, simple or compound,
open reduction......... 20.0 7. 0
0980 Phalanx or phalanges, one toe,
simple, closed reduction ... 3.0 T
0982 one toe, simple or com-
pound, open reduction.... 12.0 5.0
JOINTS
Incision
ARTHROTOMY or capsulotomy with ex-
ploration, drainage or removal of loose
body, e. g., osteochondritis or foreign
body. 30.0 8.0
1001 Shoulder ...... , .. .
1002 Elbow .............. 30.0 8.0
1003 Wrist .............. 30.0 7.0
1006 Other joints of upper ex-
tremity ............. 20.0 5. 0
1007 Hip ........ ...... 50.0 10.0
1008 Knee ............... 40.0 8.0
1010 Ankle .. .... . 30.0 8.0
1013 Other joints of lower ex-
tremity 20.0 5.0
1017 Finger, one .......... 10.0 5.0
1026 Toe, one . ... . 10.0 5.0
*1046 Arthrocentesis: puncture for
aspiration of joint, or injec-
tion of medication, initial .. 2.0
1047 subsequent .......... 1.5
1050 Sesamoid bone, excision,
one or more, unilateral .. 15.0 6.0
Excision
ARTHRECTOMY - Excision of joint
(see Arthrodesis).
1061 Punch biopsy of synovial
membrane............. 3.0
1065 Temporomandibular joint,
unilateral ............. 60.0 13.0
1074 Excision of intervertebral
disk 70.0 13.0
1075 with spinal fusion ...... 100.0 18.0
1077 Excision of neural arch and
nerve exploration for
spondylolisthesis ........ 80.0 15.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
1.082 Meniscectomy: excision of
semilunar cartilage. of knee
joint . ..... .......... 40.0 8.0
1085 temporomandibular joint ... 50.0 9.0
1093 Synovectomy, elbow........ 60.0 10.0
1101 hip, complete ... ....... 80.0 14. 0
1102 knee ................ 50.0 10.0
1103 ankle ................ 40.0 9.0
Introduction
1131 Arthrography: injection of
air or radiopaque material
into joint for roentgen exam -
ination (X-ray charges not
included) ............... 3.0
Repair
ARTHROPLASTY - Plastic or recon-
structive operation on joint, any type.
1141 Shoulder .............. 70.0 15.0
1142 Elbow ................. 60.0 12.0
1143 Wrist ................ 50.0 10.0
1144 Finger, one joint ........ 20.0 6.0
1150 Hip ................. 100.0 18.0
1151 Knee ................. 80.0 15.0
1152 Ankle ................ 60.0 12.0
1153 Toe, one joint .......... 15.0 6.0
1.162 Metatarsophalangeal joint;
bunion operation ...........25. 0 7. 0
ARTHRODESIS - Fusion of joint, with
or without tendon transplant.
1166 Shoulder .............. 70.0 15.0
1167 Elbow ................ 60.0 13.0
1168 Wrist ..... .......... 50.0 10.0
1170 Finger, thumb, one joint... 15.0 5.0
1175 Hip ................. 100.0 17.0
1176 Knee ................ 70.0 14.0
1177 Ankle ............... 60.0 12.0
1178 Hammer toe, operation,
one toe ............... 20.0 5. 0
1181 Hallux rigidus, repair of... 25.0 8. 0
1183 Tarsal, joints, one or more 30.0 8.0
1184 Other joints, lower extremity 30.0 7. 0
1185 Foot, triple arthrodesis, uni-
lateral .............. 50.0 9.0
1187 Foot, with tendon transplanta-
tion .. 60.0 12.0
1190 . *Stl'ijit'to4Vj~)iUs }Jy bbiie.
ljlQcX.,..,..,...,..., 40.D 8:0
.. . ... . . . . ... . .
Form 785MGI
Suture
1201 Capsulorrhaphy: suture or
Surg. Anes.
repair of joint capsule (in-
dependent procedure) for re-
current dislocation, shoulder. 70.0 12.0
1202 patella ......... , ... 50.0 9. 0
1211 Suture of torn, ruptured or
severed collateral ligaments,
knee ... ........ ? 40.0 8.0
1212 Suture of torn, ruptured or
severed cruciate ligaments,
knee ........... . ... 40.0 8.0
1213 Suture of torn, ruptured or
severed collateral and
cruciate ligaments, knee ... 60.0 11.0
1215 Reconstruction, both col-
lateral or cruciate ligaments,
knee ...... 70.0 15.0
1216 Reconstruction, both col-
lateral ligaments, ankle.... 50.0 10.0
1217 Reconstruction, both
metacarpophalangeal or
interphalangeal ligaments . . . 30.0 8.0
Manipulation
Manipulation of joint under general
anesthesia, including application of
cast or traction (independent pro-
cedure). (Dislocations excluded.)
*1221 Shoulder............ 5.0 T
*1222 Elbow .............. 4.0 T
*1223 Wrist .............. 4.0 4.0
*1224 Digits, one or more, under
anesthesia, where no other
surgical procedure is per-
formed ....... ..... 2.5 T
*1226 Hip ................ 6.0 T
*1227 Knee ............... 5.0 T
*1228 Ankle .............. 4.0 T
*1232 Spine .. ... ... .. 6.0 T
*1233 Manipulation of shoulder for
fibrous ankylosis, under
general anesthesia .. 5.0 T
1241 Turnbuckle jacket, body
only, for scoliosis ... . 10.0
1242 Turnbuckle spica jacket for
scoliosis ... .... 12.5 4.0
*1244 Club foot and application of
cast, unilateral ........ .2.0 T
*1245 application of subsequent
casts, unilateral .... 2.0 T
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
*1246 application of cast,
bilateral, initial ....... 3.0
*1247 application of subsequent
casts, bilateral........ 3.0
*1248 wedging cast ........... 1.0
Dislocations
*1251 Temporomandibular, simple,
closed reduction .......... 5.0
1256 Vertebra, cervical, simple,
closed reduction with general
anesthesia ... .. 40.0
1258 cervical, simple or com-
pound, with operation ..... 80.0
1262 dorsal, simple, closed re-
duction with general anes-
thesia ................ 40.0
1264 dorsal, simple or com-
pound, with operation ..... 80.0
1267 lumbar, simple, closed
reduction with general
anesthesia ............ 40.0
1270 lumbar, simple or com-
pound, with operation ..... 80.0
1273 Clavicle, sternoclavicular,
simple, closed reduction .... 10.0
1274 compound, with general
anesthesia .... .. .. 20.0
1275 simple or compound, open
reduction ............. 30.0
1278 acromioclavicular, simple,
closed reduction ........ 7.0
1281 simple or compound,
open reduction ........ 30.0
*1284 Shoulder (humerus), simple,
closed reduction .......... 5.0
1286 simple or compound, open
reduction . 40.0
1290 Elbow, simple, closed . reduc-
tion . ... 8.0
1291 compound, with general
anesthesia ............ 16.0
1292 simple or compound, open
reduction ............. 40.0
1295 Wrist, carpal, one bone,
simple, closed reduction .... 7.0
1296 compound, with general
anesthesia . . . . . 14.0
1297 ! ? sifte;vr cMpOu; j, lVir ? ;, ?
feVyeti, n
1298 l m ore tit n one bnrT, s#np1j, : ?
closed reduction ... 10.0
1300 compound, with general
anesthesia........... 20.0
Form 785MGI
Surg. Anes.
1301
T
1304
T
1305
1306
*1315
1316
5.0
1317
15.0
*1326
1327
5.0
1328
15.0
1332
1334
5.0
1338
15.0
1344
4.0
1345
4.0
1346
7. 0
1350
4.0
1351
7.0
1352
4.0
1355
9.0
1356
4.0
1357
5.0
1361
9.0
1362
4.0
1363
5.0
1371
1372
4.0
1373
5.0
simple or compound, Surg. Anes.
open reduction ....... 40.0 9. 0
Metacarpal, one bone,
simple, closed reduction ... 5.0 4. 0
one bone, compound ..... 10.0 4.0
simple or compound,
open reduction ....... 20.0 5. 0
Finger, one, one or more
joints, simple, closed re-
duction ............... 3.0 T
compound ............ 6.0 4. 0
simple or compound, open
reduction ............ 12.0 5.0
Thumb, simple, closed re-
duction . ....... 3.0 T
compound ............ 10.0 4.0
simple or compound, open
reduction ............ 1.5.0 5. 0
Hip (femur), simple, closed
reduction . 15.0 4.0
simple or compound, open
reduction ............ 50.0 10.0
congenital, closed reduc-
tion .. ' . 15.0 5.0
Knee (tibia), simple, closed
reduction .. 10.0 4.0
compound, with general
anesthesia ........... 20.0 4.0
simple or compound, open
reduction ....... . .... 50.0 9. 0
Patella, simple, closed re-
duction ............... 5.0 4.0
compound, with anesthesia 10.0 5.0
simple or compound, open
reduction ............ 30.0 8. 0
Ankle, simple, closed re-
duction ............... 10.0 4.0
compound, with general
anesthesia ........... 20.0 5. 0
simple or compound, open
reduction ............ 40.0 9. 0
Tarsal, simple, closed re-
duction ............. :. 10.0 4.0
compound, with general
anesthesia ........... 20.0 5. 0
simple or compound, open
reduction ............ 35.0 6. 0
Astragalotarsal, simple,
closed reduction......... 10.0 4.0
compound, with general
anesthesia ........... 20.0 5.0
simple or compound, open
reduction ............ 35.0 6.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
3
1
76 Metatarsal, one bone, simple,
closed reduction. .........
1377 compound .............
1378 simple or compound, open
reduction .............
1385 Toe, one, simple, closed
reduction.. .... .. . . . .
1386 compound......;.
1387 simple or compound, open
reduction .............
1391 more than one, one or more
joints, simple, closed re-
duction...
1392 compound ...........
Incision
5.0
4.0
10.0
5.0
20.0
6.0
3. 0
T
.6.0
4,0
12.0
5. 0
5.0
4.0
10.0
4.0
3.0
15.0
T
20.0
T
2. 0
1.5
2.0
1.5
2.0
1.5
*1401 Drainage of infected bursa ...
1406 Removal of subdeltoid cal-
careous deposits..........
1410 Removal of subtrochanteric
calcareous deposits .......
*1413 Puncture for aspiration of
bursae, initial ...........
*1418 subsequent ............
*1424 Needling of bursa ..........
*1425 subsequent ............
*1427 with irrigation of bursa....
*1428 subsequent with irrigation
of bursa ..............
Excision
1430 Radical excision of bursae,
forearm, viz. , tenosynovitis
fungosa, Tbc., and other
granulomas ............. 50.0 10. 0
1431 Excision of bursa, olecranon . 15.0 5. 0
1433 prepatellar ............ 15.0 5.0
1435 subacromial ........... 20.0 6. 0
1436 ischial ............... 20.0 6. 0
Incision MUSCLES
1450 Removal of foreign body in
muscle, general anesthesia .. 10.0 T
1454 Division of scalenus anticus,
without resection of cervical
rib .. 25.0 6.0
1456 it reQeetiQ2t,o; crFvJ at ?
1458 vis on of teerno atoidf `p "7~~"; 15. 0
a r
torti ollis, open operation .. 25. a 7. 0
1460 Muscle biopsy, superficial. . . 4.0
Form 785MGI
Surg. Anes.
1495 Suture of ruptured -s, r,..~~.
diaphragm ............. 60.0 13.0
TENDONS, TENDON SHEATHS AND FASCIA
Incision
*1511 Drainage of tendon sheath,
infection for acute tenosyno-
vitis, one digit . . . . . , . . . 2.0
1514 Drainage of tendon sheath,
infection for tenosynovitis,
single palm and/or wrist,
ulnar or radial bursa infec-
tion, in hospital ... . . . . . . 30.0 5.0
*1517 Injection of medication,
tendon sheath, hand. . . 1.0
1519 Incision of fibrous sheath of
tendon for stenosing teno-
synovitis, to include freeing
of tendons or removal of
foreign body, in hospital . , . 20.0 6. 0
1531 Division of iliotibial band,
open operation .. . , .. 30.0 7. 0
1534 Stripping of ilium (Soutter
operation) . . . . . . . . . . . . . 40.0 8.0
*1535 Tenotomy, corrective, single
digit, subcutaneous ... . . . . 5. 0 4. 0
1536 corrective, multiple. . . . . 10.0 T
1539 hip adductors, subcu-
taneous . . . . . . . . . . . . . 10.0 4.0
1541 open .............. 30.0 6.0
Excision
1550 Excision of small ganglion
cysts . 4.0 4.0
1552 Excision of lesion of tendon
or fibrous sheath, including
ganglion, digits only . . . . . . 10.0 4. 0
1553 in other locations. . . . , . 20.0 T
1555 Radical excision of bursae,
forearm, viz. , tenosyno-
vitis fungosa, Tbc. l and
other granulomas (see 1430).
1562 Excision of Baker's cyst
(synovial cyst of popliteal
space)...., 30.0 8.0
1570 Fasciotomy, single, palm or~
sole, subcutaneous, blind . , 10.0
1573 for Dupuytren's con-
tracture, partial ....... 30.0 7.0
1574 including finger ex-
tensions and vertical
bands, radical . . . . . . . 50.0 T
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Repair
1580 Repair or suture extensor
tendon, single, hand or foot,
Surg. Anes.
distal to wrist or ankle . . 10.0 T
1582 single, forearm or leg .... 15.0 T
1583 Repair or suture flexor
tendon, single, unless other-
wise listed.......... ... 20.0 T
1585 Transfer, or transplant, or
free graft of tendon, single,
distal to elbow, distal to knee. 30. 0 T
1586 single, elbow to shoulder,
knee to hip............ 50.0 T
1587 Tenolysis, single .... . . . . . 20.0 T
1589 Lengthening or shortening
tendon ... 20.0 T
1592 Retrieve or reroute tendon
through separate incision,
add 25% of appropriate fee.
1612 Free fascial graft for recon-
struction tendon pulley or
repair bowstring tendon,
single (independent pro-
cedure) ................ 10.0 T
1613 for reconstruction tendon
pulley or repair bowstring
tendon to form gliding sur-
face for tendons......... 10.0 T
1616 Abdominal fascial transplants,
bilateral . ....... 60.0 T
1632 Patellar advancement . 50.0 10. 0
1633 Ruptured quadriceps insertion. 30.0 8. 0
1640 Ruptured biceps tendon from
insertion elbow........... 30.0 8. 0
1641 Flexor-plasty, elbow....... 50.0 11.0
1654 Repair ruptured supraspinatus
tendon or musculotendinous
cuff shoulder .... . . . . . .. 40.0 9. 0
1655 Suture of complete shoulder
cuff avulsion ... . . . . . . . .. 70.0 17.0
Incision
EXTREMITIES
Amputation
Upper Extremity
Surg. Anes..
1701 Interthoracoscapular ...... 100.0 19.0
1703 Disarticulation of shoulder.. 70.0 14.0
1705 Arm through humerus...... 30.0 7. 0
1708 Forearm, through radius
and ulna ? . 30..0 7. 0
1710 Guillotine upper arm ..... 30.0 7. 0
1711 with subsequent revision
or reamputation (same
surgeon) ............ 40.0 7.0
1712 Cineplasty, complete pro-
cedure .... 60.0 13.0
1718 Disarticulation of wrist . , .. 30.0 7. 0
1722 Hand through metacarpal
bones .. 30.0 T
1725 Metacarpal, with finger or
thumb, one, with split or
Wolff graft, or skin-plasty
and/or tenodesis with
definitive resection palmar
digital nerves ......I .... 20.0 T
1737 Finger, any joint, or
phalanx, one, with split or
Wolff gram, or skin-plasty
and/or tenodesis, with
definitive resection volar
digital nerves .......... 12.5 T
Lower Extremity
1748 Disarticulation of hip ..... 80.0 18. 0
1750 Disarticulation of knee .... 40.0 6. 0
1752 Thigh through femur, in-
cluding supracondylar ..... 50.0 10. 0
1760 Guillotine, thigh......... 40.0 8.0
1763 with subsequent revision
or reamputation (same
surgeon) ............. 50.0 8. 0
1767 Leg, through tibia and
fibula . . 40.0 8.0
1771 Guillotine, leg .......... 30.0 8. 0
1774 with subsequent revision
or reamputation (same
surgeon) ... . . . . . . . ... 40.0 8.0
1778 Ankle (Syme, Pirogoff), with
skin-plasty and resection
nerves 40.0 T
1782 Foot, transmetatarsal, each
foot ............... 30.0 T
1785 midtarsal ............ 30.0 T
1788 Metatarsal with toe, split or
Wolff graft, or skin-plasty
and/or tenodesis, with de-
finitive resection digital
nerves. . . . . . . . . . . . . . . . 20.0 T
1682 ' Drainage of felon in hospital
with general anesthesia ..... 10.0 4. 0
1686 Drainage of single infected
space of hand (lumbrical,
hypothenar, thenar, middle
palmar, etc.) with or without
tendon sheath involvement, in
hospital .... .?...:.?. oo?. t .%?15%Or.. :10
1692 Drainage of'rpu2tiil&1nfcte4 !
spaces of ljtd Rwiti- pr with -: = -. ? :
out tendon sheath involvement)
in hospital .............. 30.0 5.0
Form 785M01 -11-
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
1. 802 Toe, any joint or phalanx, one. 10. 0 T
1.803 Toe, more than one, split or
Wolff graft, or skin-plasty
and/or tenodesis, with de-
finitive resection digital nerves 15. 0 T
Repair
1811 Freeing of web fingers, with
flaps . ................. 25.0 7.0
1815 with graft ............. 35.0 10.0
PLASTER CASTS (INDEPENDENT PROCEDURE ONLY)
*1851 Molded plaster to forearm ... 2.0 T
*1854 elbow to fingers ......... 2.0 T
*1856 hand and wrist .......... 2.0 T
*1860 shoulder to hand ........ 3.0 T
*1862 shoulder spica .......... 5.0 T
*1865 ankle (foot to midleg) ..... 2.0 T
*1867 knee (foot to thigh) ....... 4. 0 T
*1871 Ambulatory leg cast... . .... 3.0 T
*1875 Molded plaster to leg ...... 2.0 T
*1878 Spica, unilateral (hip to foot) . 6.0 T
*1882 bilateral 7.0 T
*1885 Body, shoulder to hips ...... 7.0 T
*1886 including head .......... 8.0 T
*1891 Unna boot .............. 2.0 T
RESPIRATORY SYSTEM
Incision
*1901 Drainage of nasal abscess .. 1.5
*1905 Drainage of septal abscess ... 2.5
Excision
*1911 Biopsy, soft tissue, nose .... 2.0
*1915 Excision of nasal polyp...... 2.0
1916 Excision nasal polyps,
multiple, unilateral or
bilateral, one or more stages,
office ........ 5.0
1917 hospital, with anesthesia... 15.0 5.0
1922 Excision of nasopharyngeal
fibroma ... 35.0 T
1924 Excision of skin of nose for
rhinophyma ............. 30.0 7.0
1928 Submucous resection (nasal
000 ?
septum, lVcllzdilh.; gepto lastyJ - 30t
1935 Resection df.t i.nS!e (sub-: ' ::: ?
mucous), pp?nolete:oa pailial,. * ? ?
unilateral or bilateral (inde-
pendent procedure) ........ 10.0 7.0
Form 785MGI
Endoscopy Surg. Anes.
*1941 Rhinoscopy with removal of
foreign body in nose ....... 2.0
Repair
1950 Rhinoplasty, complete
external parts (including bony
pyramid, lateral cartilages,
and tip as necessary) . . . . 70.0 13. 0
1953 nasal bridge collapse, bone
or cartilage graft (see 0619,
0621 or 0622)
1956 tip only 40.0 7.0
1957 secondary minor revision . 10.0
1958 total or major partial re-
construction (see 0260 to
to 0325, 0169 to 0622)
Destruction
*1965 Cauterization of turbinates,
unilateral or bilateral (inde-
pendent procedure) .. . , . . . 2.0
Manipulation
1970 Reduction of fractured nasal
bones (see 0686 to 0688)
*1971 Control of primary nasal
hemorrhage with cauteriza-
tion of septum . . . 2.0
1978 by ligation of ethmoid
artery .............. 25.0 7. 0
Incision
*1981 Antrum puncture, unilateral . 2.0
1985 Maxillary sinusotomy, simple,
antrum window operation,
unilateral ... . . , . . . . , 15.0 7.0
1986 bilateral 20.0 7.0
1988 Radical (Caldwell-Luc), uni-
lateral . . . . . . 40.0 9.0
1991 Sphenoid sinusotomy ...... 25.0 7. 0
1992 Frontal sinusotomy, external,
simple, (trephine operation) . 20.0 7.0
1993 radical 50.0 11.0
1994 Combined external frontal,
ethmoid and sphenoid sinuso-
tomy, unilateral . , .... . .. 70.0 15. 0
Excision
2006 Ethmoidectomy, intranasal,
unilateral . 20.0 7.0
2013 external, unilateral ..... 25.0 7.0
2016 bilateral 35.0 9.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Suture
2031 Closure of dental fistula of
Surg. Anes.
2126 Bronchospirometry and
catheterization of bronchi
Surg. Anes.
maxillary sinus with flap or
radical antrotomy ......... 40.0 12.0
2032 Closure of oronasal fistula
(local mucoperiosteal ped1cle
flaps) .......... ...... 30.0 11.0
Incision
2041 Laryngofissure with removal of
tumor ................ 50.0 14.0
Excision
2051 Laryngectomy, without neck
dissection .............. 80.0 17. 0
2055 Hemilaryngectomy ........ 80.0 17.0
2057 Epiglottidectomy, external
approach .............. 70.0 14.0
2058 endoral approach ........ 25.0 7. 0
Introduction
2061 Injection of radiopaque sub-
stance into larynx for
bronchography, indirect
method ............... 3. 0
2063 direct with bronchoscope... 5.0
Endoscopy
2071 Laryngoscopy, direct, diag-
nostic (independent procedure). 10.0 7. 0
2074 with biopsy ............ 15.0 7.0
2077 operative, including re-
moval of foreign body. .... 15.0 7.0
2081 including removal of
papilloma or other tumor .. 20.0 7. 0
*2085 subsequent, indirect...... 1.0
2087 Lynch suspension, in hospital. 10.0 7.0
Incision
2101 Tracheotomy (independent pro-
cedure) ................ 20.0 7.0
Endoscopy
2111 Bronchoscopy, diagnostic .... 15.0 7.0
2113 with biopsy ............ 15.0 7.0
2117 with removal of foreign body 25.0 7.0
2120 with excision of tumor.... 25.0 7.0
2121 with aspi*r,atign c~.larouchus 15P. G ? + 0
2122 with draijiagp Df:ung:a.l3soess - ?
or cavity,?iiitial:...;.. :. '15?x 0 ?:0
2123 with lips ol?injet;tfon.*..'. ' 1r. d ~. 0
2124 subsequent ............ 10.0 7. 0
Form 785MGr
(independent procedure) .... 25.0 7.0
2127 Tracheal aspiration (inde-
pendent procedure) under
direct vision............ 10.0 6.0
*2128 indirect ............. 1.0
Repair
2132 Tracheoplasty:intrathoracic. 75.0 21.0
2133 Bronchoplasty (graft repair) . 90. 0 22.0
2134 (excise stenosis and
anastomosis).......... 90.0 22.0
2135 with lobectomy and
anastomosis .......... 100.0 26.0
Suture
2141 Tracheorrhaphy: suture of
external tracheal wound or
injury, depending on struc-
ture and extent of injury
(cervical) ............. 30.0 8. 0
2142 (intrathoracic)......... 75.0 13.0
2144 Closure of tracheostomy or
tracheal fistula ......... 20.0 7.0
2147 Closure of tracheo-esopha-
geal fistula ............ 75.0 25. 0
Incision
2151 Thoracotomy, exploratory,
including control of hem-
orrhage and/or biopsy and
cardiac massage ......... 50.0 15.0
2154 with open drainage of em-
pyema cavity by rib re-
section (independent proce-
dure) ... ... .. 35.0 10.0
2157 with closed drainage of
empyema cavity; tube
drainage with negative
pressure (independent
procedure) . ? ...... 10.0 5.0
2160 with removal of intra-
pleural foreign body or
fibrin body ... .. .... 70.0 16.0
2163 with open intrapleural
pneumono lys is......... 70.0 16.0
2166 Pneumonotomy, exploratory. 50. 0 15.0
2170 with open drainage of pul-
monary abscess or cyst .. 60.0 16.0
2173 with removal of foreign
body from lung ........ 60.0 16.0
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
2176 Cruciate incision of thickened
scar deposited on visceral
pleura ............... 60.0 15.0
2177 Total pulmonary decortication. 100. 0 24.0
2180 Pneumonocentesis: puncture of
lung for aspiration biopsy.... 15.0
*2183 Thoracer.tesis: puncture of
pleural cavity for aspiration,
initial ................. 3.0
*2186 subsequent ............ 2.0
Excision
2191 Total pneumonectomy ...... 100.0 24.0
2193 Total or subtotal lobectomy .. 100.0 24.0
2194 Wedge resection .......... 75.0 21.0
2196 Pleurectomy, any type (inde-
pendent procedure) ........ 80.0 21.0
Endoscopy
2201 Thoracoscopy, exploratory
(independent procedure) ..... 20.0
2204 with biopsy ............ 20.0
2207 Closed intrapleural pneumo-
nolysis ................ 30.0
Surgical Collapse Therapy
THORACOPLASTY - Extrapleural re-
section of ribs, any type.
2211 first stage ............ 50.0 12.0
2212 second stage ........... 30.0 10.0
2213 third stage ............ 30.0 10. 0
2217 Extrapleural pneumonolysis,
including associated filling or
packing procedures ........ 50.0 12. 0
*2221 Pneumothorax: intrapleural
injection of air, initial...... 5.0
*2222 subsequent ............ 2.0
Incision
2301 Cardiotomy with exploration
or removal of foreign body. . . 100.0 26.0
2305 Pericardiotomy with explora-
tion, drainage or removal of
foreign body.. ......... 80.0 21.0
*2310 PericardiocQntis,.~xncbure
of pericart1 al p~ace.fon ? ? F
aspiration ............... ?. r 5~ 0, ? ,
*2311 subsequent .?...'." . ~.. 3. 0
2315 Valvulotomy or commissuro-
tomy ................. 100.0 25.0
Form 785MGI
-11+-
25.0
21.0
2316
Operation for regurgitation. .
100. 0
2317
Operation for coronary
disease (poudrage) ........
50.0
Excision
2321
Pericardiectomy .........
100.0
2325
Valvulectomy ...........
100.0
2326
Excision of auricular
appendage .............
60.0
24. 0
25.0
24.0
Introduction
2331 Catheterization of the heart
(independent procedure) by report
right only ............ 20.0 6. 0
left only ............. 15.0 6.0
both ... .... 30.0 6.0
2332 Injection for angiocardio-
grams ..... 5.0
2333 Retrograde aortography -
cut down and pass catheter.. 20.0
Destruction
2341 Cardiolysis ............ 60.0 20.0
2345 Pericardiolysis .......... 60.0 20.0
Suture
2351 Cardiorrhaphy: suture of
heart wound or injury ..... 80.0 23.0
2352 suture I-A septal defect .. 100. 0 24.0
2355 Pericardiorrhaphy: suture of
pericardial wound or injury . 70. 0 20.0
Incision
ARTERIOTOMY - With removal of
embolus :
2
373
Trunk .............
2
376
Neck .............
2
380
Extremity ...........
PHLEBOTOMY - With removal of
thrombus:
2397
Trunk
2401
Neck
............
2404
Extremity ...........
Surg. Anes.
60.0 11.0
50.0 11.0
50.0 10. 0
50.0 11.0
50.0 11.0
35.0 9. 0
Excision
2426 Excision of coarctation of
aorta ............... 100.0 24.0
2427 Repair of thoracic or
abdominal aorta ........ 100.0 22.0
2428 Popliteal aneurysm ...... 60.0 11.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
2431 Filipuncture: wiring of
down
p
roced
ure) .......... 3.0 T
2450 Push transfusion, given under
two years of age .......... 10.0 T
*2454 Injection of sclerosing solu-
tion into vein of leg, initial,
unilateral ...... 1.0
2461 subsequent, unilateral .... 1.0
Repair
2472 Repair of aortic arch'
anomalies .... ......... 80.0 T
ARTERIAL ANASTOMOSIS:
2475 Aortic anastomosis .. . 100.0 25. 0
2478 Pulmonary aortic anasto-
mosis (Pott's) .......... 100.0 25.0
2482 Pulmonary subclavian
anastomosis (Blalock) ..... 100.0 25. 0
2485 Pulmonary innominate
anastomosis (Blalock) ..... 100.0 25.0
VENOUS ANASTOMOSIS:
2490 Portocaval anastomosis.... 100.0 23.0
2496 Splenorenal anastomosis ... 100.0 21.0
Suture
2511 Arteriorrhaphy: suture of
wound or injury of artery .... 30.0 T
2515 Phleborrhaphy: suture of
wound or injury of vein ..... 20. 0 7.0
2520 Ligation and division of
ductus arteriosus ......... 80.0 17. 0
2522 Ligation of carotid artery ... 40.0 7 0
2525 Ligation a q,d tliQfsio' 'df 3nf~ei tor- -: :. = -
vena cava .'y? it i+ ? .; ;0.0:' 11: c r.:
2526 Ligation of?j:dmpral;vrln'.'. 25. 0.-? 6* 0
?
2530 Ligation and division of com-
mon iliac vein ........... 40.0 7. 0
Form 785MGI
aneurysm, extremity ...... 20.0
2432 wiring of aneurysm, aorta.. 30.0
2434 Arteriography (exclusive of
X-ray allowance) ......... 10.0
2435 (exclusive of X-ray allow-
ance) lumbar........... 10.0
2440 Venography (exclusive of
X-ray allowance).......... 5.0
2445 Blood transfusion, indirect
method....., 2.0
2446 replacement type, Rh factor. 25. 0
2448 direct method ........ ? 5.0
2449 Incision into and exposure of
vein for introduction of medi-
cation and fluid (separate cut-
2558
7.0
11.0
7.0
2561
7.0
7.0
2563
2576
2581
2585
Ligation and division of long Surg. Anes:
saphenous vein at sapheno-
femoral junction with or with-
out retrograde injection, or
distal interruptions ........ 17.5 7. 0
Ligation and division and
complete stripping of long
or short saphenous veins . . . 25.0 9.0
of long and short
saphenous veins. ? . 35.0 10. 0
Ligation and division of short
saphenous vein at saphe-
nopopliteal junction .. . .... 10.0 5. 0
of minor varicose vein of
leg, initial... 5.0
subsequent ......... 3.0
HEMIC AND LYMPHATIC SYSTEMS
SPLEEN
2601 Splenecto.-ny ........... 60.0 11.0
LYMPH NODES AND LYMPHATIC CHANNELS
Incision
*2631 Drainage of lymph node
abscess or lymphadenitis...
2.0
T
Excision
2641 Biopsy of lymph node .....
5. 0
4. 0
2642 of lymph node (anterior
scalene) .............
15.0
4.0
2644 Excision of lymph node ....
5.0
4.0
RADICAL LYMPHADENECTOMY -
Radical resection of lymph nodes.
2652
2
Upper neck ... . ......
40.0
13.0
658
Axilla ..............
40.0
10.0
2665
Cervical (complete), uni-
26
lateral .............
60.0
15.0
72
Groin ..............
40.0
12.0
Incision
MEDIASTINUM
2680
Mediastinotomy with explora-
tion or drainage ........
70.0
15.0
2683
Foreign body removal,
cervical ..............
70.0
16.0
Excision
2691
2
Excision of mediastinal cyst. 80, 0
18.0
693
Excision of mediastinal tumor 80. 0
19.0
Approved For Release 2009/05/26: CIA-RDP68-00140R000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
2696 Repair thoracic duct
Surg. Anes.
(suture) ................ 70.0 17.0
2697 Plastic.anastomosis, thoracic
duct .................. 80.0. 19.0
DIGESTIVE SYSTEM
Incision
*2 701 Drainage of sublingual abscess 2. 0
*2705 Drainage of Ludwig's angina. . 7.0
Excision
2742 V-excision of small lesion of
lip (see 0178 to 0190)
2743 V-excision of large lesion of
lip up to one-half lip ...... 15.0 6. 0
2744 Resection of more than one-
half lip with plastic closure
(see 0260 to 0325).
2746 without plastic closure . . . . 15.0 7. 0
2747 Secondary plastic closure
(see 0260 to 0325).
Repair
2751 Cheiloplasty: plastic or re-
construction operation on lip
(see 0260 to 0325).
2754 Plastic repair of harelip,
primary, unilateral....... . 60.0 12. 0
2758 primary, bilateral, one
stage...... 80.0 15.0
2759 bilateral, two stages,
per stage ........... 60.0 12.0
2761 secondary, local revision,
unilateral or bilateral
(see 0260 to 0325).
2762 Plastic repair of unilateral
harelip by recreation of de-
fect and rec losure......... 60.0 12.0
2765 ' Plastic repair of bilateral
harelip by recreation of de-
fect and reclosure - per
major stage..... ...... 60.0 12.0
Incision (Glossotomy) TONGUE
*2771 Drainage of ln4$al;a'b'so,ess i ,:. gi0:?*
? ? ? ? ? ? ? ? ? ?
Excision (Glossectc r): ??? ; ;?,
2781 Biopsy of tongue .......... 2.0
Form 785MGI
2785 Partial glossectomy or
hemiglossectomy
Surg. Anes.
(e lectrocoagu I ation)....... 30.0 12.0
2787 Complete or total
glossectomy ........... 60.0 15.0
Repair
2791 Glossoplasty: plastic opera-
tion on tongue (see 0260 to
0325).
Suture
2801 Glossorrhaphy: suture of
tongue wound or injury
(see 0260 to 0262).
Incision
TEETH AND GUMS
*2815 Drainage of alveolar abscess,
acute with cellulitis - oral . . 2. 0
Incision
PALATE AND UVULA
*2871 Incision and drainage of
palate (abscess) . . . . . . . . . 2.0
Excision
2881 Biopsy of palate ......... 2.0
2883 Excision of local lesion of
palate (see 0178 to 0190,
0260 to 0267).
2884 with graft or flap closure
(see 0275 to 0325).
2885 Resection of palate or wide
excision of lesion of palate, . 35. 0
9. 0
2886 Resection of palate with re-
construction (see 0275 to
0325).
2887 Uvulectomy: excision of
uvula ................ 3.0
Repair
2890 Palatoplasty: plastic opera-
tion for partial cleft palate. . 50. 0 10.0
2892 plastic operation for com-
plete cleft palate, includ-
ing alveolar ridge . ..... 70.0 15. 0
2894 secondary minor revision
(see 0260 to 0276).
2895 major revision ... . . . .. 50.0 12.0
2897 secondary lengthening
procedure . . . , 70.0 15.0
2898 attachment pharyngeal flap. 50.0 10.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Suture Surg. Anes.
2901 Suture palate wound or Injury
(see 0265 to 0267).
Inc is ion
2911 Drainage of parotid ac2scess .. 5.0 4.0
*2915 Sialolithotomy: removal of
salivary calculus, local
anesthesia .............. 5.0
2916 Sialolithotomy, extraoral.... 25. 0
Excision
2921 Biopsy of salivary gland..... 5.0 4.0
2927 Excision of parotid tumor . . . 40.0 T
2930 of submaxillary tumor . . . . 30.0 7. 0
2931 of submaxillary gland..... 30.0 7. 0
2934 of parotid gland with pres-
ervation of facial nerve . . . 60.0 T
2937 with sacrifice of facial
nerve ....... . ...... 50.0 T
Repair
2941 Plastic repair of salivary
duct: sialodochoplasty ...... 30.0 7.0
Suture
2951 Closure of salivary fistula . . . 40.0 8. 0
Manipulation
*2961 Dilation of salivary duct;
ptyalectasis ............. 2.0
Surg. Anes.
3000 Excision of tonsil tag, uni-
lateral, hospital ........ 10.0 5.0
3002 unilateral, office, local
anesthesia ........... 6.0
3004 Excision of lingual tonsil
(independent procedure) ... 10.0 5. 0
Repair
3011 Pharyngoplasty: plastic or
reconstructive operation on
pharynx (see 0260 to 0319).
Suture
3021 Suture of external wound or
injury of pharynx ....... 10.0,
Incision
3031 Esophagotomy .......... 60.0 10.0
3032 for removal of foreign
body .. .......... 60.0 10.0
3033 intrathoracic ......... 70.0 16.0
Excision
3043 Esophagectomy: resection
of esophagus, transpleural
or extrapleurat s . 100.0 20. 0
3044 Local excision, end-to-end
anastomosis............ 90.0 20.0
Endoscopy
3051
PHARYNX, ADENOIDS AND TONSILS
3053
Incision
2971
Drainage of retropharyngeal
3055
abscess, internal approach...
5.0
3057
2972
in hospital .....
10.0
6.0
3061
2977
Drainage of peritonsillar
3063
abscess.. ............
3.0
2978
in hospital ............
10.0
6.0
Repair
*2982
Biopsy of pharynx ........
2.5
3071
2984.
Excision of pharyngoesophageat
diverticulum, first stage ....
20. 0
9.0
2986
second stage...........
20.0
9.0
3072
2987
single stage ...........
40.0
11.0
2989
Excision branchial cleft cyst
3073
or vestige, confined to skin
3074
and subcutaneous tissues ....
15.0
6.0
3075
2990
extendin
beneath is b .
c
cutaneous tissiteq..~. ' .w ? &U: O:? 1a.o ?
?
3076
9
i
l
2
92
Tons
ectomy `wit;
l
or yvi$h;
out adenoidv i&my,:any age ??.
15'0??? S.0 ?
Suture
2996
Adenoidectomy (independent
3081
procedure) ..............
10.0
Form 785MGI
Esophagoscopy, diagnostic. . 15.0 6.0
with insertion of radio-
active substance ....... 15.0 6.0
with biopsy........... 15.0 6.0
with foreign body removal. 20.0 7.0
with dilation, direct..... 15.0 6.0
subsequent ........... 10.0 6.0
Esophagoplasty: plastic
repair or reconstruction of
esophagus ............. 100.0 22.0
Esophagogastrostomy
(cardioplasty)........... 60.0 15. 0
Esophagoduodenostomy . . . . 60.0 20. 0
Esophagojejunos.tomy ..... 100.0 24.0
Esophagostomy; fistulization
of esophagus, external . . . . 40.0 11.0
Esophagomyotomy (Heller). . 70. 0 15.0
Suture of esophageal wound,
injury or rupture, cervical
approach ............. 40.0 11.0
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
3083 intrathoracic ...........
3086. Closure of esophagostomy or
other external esophageal
fistula, cervical . . . .......
3087 thoracic ..............
Manipulation
3091 Dilatation of esophagus by
sound, bougie or bag, initial,
direct (see 3061).
3092 initial, indirect ...... . ..
3095 subsequent . .... . . .....
Incision
3101 Gastrotomy with exploration
or foreign body removal . . . .
3105 Pyloromyotomy: cutting of
pyloric muscle (Fredet-
Ramstedt operation) . . . . . .
Excision
3111 Biopsy of stomach, with
laparotomy . , . . .
3112 Local excision of stomach
ulcer or benign neoplasm ....
3114 ? Total gastrectomy.........
3115 Subtotal gastrectomy . . . ... .
Endoscopy (independent procedure)
3121 Gastroscopy, diagnostic.. , ..
3123 with biopsy ............
Suture
3131 Pyloroplasty ............
3133 Gastroduodenostomy .......
3135 Gastrojejunostomy, ........
3136 with partial vagectomy;
vagotomy . ......
3137 Gastrostomy for feeding.....
3141 Gastrorrhaphy: suture of per-
forated gastric ulcer, wound
or injury .. .
3144 Closure or taking down of
gastroduodenal anastomosis
(gastroduodenostomy).......
3146 Closure or taking down of
gastrojejunal anastomosis
(gastrojej pogtomy4, ....... ..
3153 Closure e1ga:ittoJtom3,
Form 785MGI
Surg. Anes.
70.0
20.0
40.0
11. 0
70.0
20.0
5.0
2.0
40.0
9. 0
50.0
9.0
50.0
9.0
50.0
10.0
100.0
17.0
70.0
14.0
15.0
15.0
50.0
10.0
50.0
10.0
50.0
10. 0
70.0
12.0
40.0
7.0
50.0
9.0
60.0
12.0
60.41
- 42.0-
:9.0`
INTESTINES (EXCEPT RECTUM)
Incision Surg. Anes.
3161 Enterotomy with exploration
or foreign body removal,
small bowel ............ 50.0 9. 0
3162 large bowel .......... 60.0 9. 0
3166 Exteriorization of intestine,
preliminary to resection;
first stage Mikulicz, resec-
tion of intestine ......... 50.0 9.0
Excision
3171 Excision of one or more
intestinal lesions not requir-
ing anastomosis, exterioriza-
tion or fistulization ....... 60.0 11.0
3174 Enterectomy: resection of
small intestine with
anastomosis............ 60.0 11.0
3176 with enterostomy ....... 60.0 11.0
3178 Colectomy: resection of
large intestine, one or two
stages, including colostomy
and closure, if necessary 80.0 T
3179 Colectomy, partial, with
anastomosis and with or
without proximal colostomy . 80.0 16. 0
3180 total, with or without
ileostomy or anastomosis. 100.0 19.0
3191 Enteroenterostomy:
anastomosis of intestines , 50.0 10. 0
ENTEROSTOMY - External fistulization
of intestines.
3193 small (ileostomy or
jejunostomy) .......... 50.0 10. 0
3195 large (colostomy)....... 50.0 10.0
3197 small or large, for
ulcerative colitis ....... 75.0 12.0
3200 Reduction of volvulus,
intussusception, internal
hernia (by laparotomy)..... 50.0 10. 0
3203 Revision of colostomy; office 10. 0
3204 hospital ... ..... ... 20.0 7. 0
3205 Cecopexy: fixation of colon
to abdominal wall ........ 50.0 8.0
Destruction
3211 Enterolysis: freeing of
intestinal adhesion ....... 50:0 10. 0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Suture Surg. Anes.
3221 Suture of intestine (enter-
orrhaphy), large or small,
for perforated ulcer, wound,
injury or rupture ......... 50.0 11. 0
3222 Suture of intestine with
colostomy ........ ...... 65.0 12.0
3225 Closure of enterostomy,
large or small intestine ..... 40.0 8.0
Excision
3231 Excision of Meckel's diver-
ticulum (diverticulectomy) ... 40.0 7. 0
3235 Excision of lesion of
mesentery .............. 50.0 9. 0
Suture
3241 Suture of mesentery ....... 40.0 8.0
Incision
3251 Incision and drainage of
appendical abscess ..... . .. 30.0 7.0
Excision
3261 Appendectomy ........... 35.0 7.0
RECTUM
Incision
*3283 Incision and drainage, peri-
rectal abscess, office ...... 2.0
Excision
3291 Complete proctectomy, com-
bines abdominoperineal, one
or two stages ............ 100.0 17.0
3292 Complete proctectomy for
congenital megacolon .. 100.0 17. 0
3294 Excision of rectal procidentia. 40.0 8.0
3296 Division of stricture in
rectum ................ 35.0 8.0
3297, Valvotomy .............. 35.0 7.0
3298 Perineal excision of recurrent
malignant tumor .......... 40.0 T
Endoscopy (independent procedure)
3311 Proctosigmoidoscopy, diag-
nostic, initial....... . 3.0 T
3312 subsequcn.......?.a (3?r ;?T ;
3313 with bid'lysy? i4it=el a . e ? ? ~.
' ?
3314 subse ' y.. :.. ~T"
3315 with ret'tibvaof ~5fi~5ill8mas ? ~~~ ?
or polyps, initial ........ 6.0 T
Form 785MGZ -19-
Surg. Anes.
3316 subsequent.......... 5.0 'T
3317 with removal of multiple
papillomas or polyps .... 9. 0 T
3319 Sigmoidoscopic control of
hemorrhage ............ 7.5 T
Repair
3321 Proctoplasty, perineal, for
stricture or prolapse .... . 35.0 7. 0
*3322 Perirectal injection of
sclerosing solution for
prolapse .. 2.5
3325 Proctopexy, abdominal, for
prolapse .............. 50.0 10.0
Suture
3331 Closure of rectovesical
fistula ............... 50.0 13.0
3333 Closure of rectourethral
fistula.. .... 50.0 13.0
3335 Closure of rectovaginal
fistula. ...... . ......... 50.0 13.0
Manipulation (independent procedure)
*3341 R.eductiot of prolapse of
rectum ............... 2.0
Incision
3353 Fistulotomy or fistulec-
tomy, simple ........... 20.0 6.0
3354 complicated or multiple .. 37.5 7.0
3355 Fistulectomy, second stage 10.0 6.0
3358 Incision and drainage of
ischiorectal abscess with
fistulotomy or fistulectomy 30.0 7.0
*3364 Sphincterotomy, anal: divi-
sion of anal sphincter ..... 5.0
Excision
3371 Fissurectomy, with or with-
out sphincterotomy ........ 15.0 6. 0
3373 Cryptectomy, single, or
multiple (independent pro-
cedure) .............. 5.0 T
3374 Papillectomy, single or
multiple (independent pro-
cedure) .............. 5.0 T
3377 Hemorrhoidectomy, external
only ... ............. 5.0 T
3380 internal and external . . . , 25.0 6.0
3382 Fistulotomy or fistulectomy
and hemorrhoidectomy . 30.0 7.0
3386 Fissurectomy and hemorrhoid-
ectomy ............... 25.0 6.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
*3392 Enucleation of external
thrombotic hemorrhoid...... 3.0 T
3395 Excision of external
hemorrhoidal tabs ........ 5.0 4.0
Introduction
*3401 Hemorrhoids, injection of
sclerosing solution ........ 1.5
Endoscopy (independent procedure)
3411 Anoscopy, diagnostic....... 1.0
3413 with biopsy . .......... 3.0
3415 with removal of foreign body 3.0
3416 subsequent ............ 1.0
3417 Control of hemorrhage -
endoscopic .............. 6.0
Repair
3421 Anoplasty, infant ......... 25.0
3423 adult ... , .......... 25.0
3425 Sphincteroplasty, anal: plastic
operation for incontinence ... 35.0
3426 Thiersch procedure for incon-
tinence and/or prolapse ..... 20.0
3427 Construction of anus, for con-
genital absence ........... 40.0
3428 combined abdominoperineal
approach. ............. 80.0
Destruction
3433 Condyloma, single or multiple,
internal ............... 7.5
3434 subsequent ............ 2.5
Incision
*3456 Aspiration biopsy of liver.... 3.0
Excision
3464 Hepatectomy, partial: resec-
tion of liver ............. 70.0
Repair
3471 Marsupialization of cyst or
abscess of liver .......... 60.0
Suture
3481 Hepatorrhaphy: suture of liver
wound or injury .......... 50.0
B'I.UA P t TRAL [' w a -' ? ?
?
?
??
Incision
3491 Hepaticotobty, tvith'e*xploratton, ?
?
drainage (hepaticostomy) or re-
moval of calculus ......... 60.0 12.0
Form 785MGY
3495 Choledochotomy or
choledochostomy with ex-
ploration, drainage or re-
moval of calculus, with or
without cholecystotomy .... 60.0 13.0
3500 Duodenocholedochotomy:
transduodenalcholedocholi-
thotomy ............... 90.0 17.0
3504 Cholecystotomy or chole-
cystostomy with exploration,
drainage or removal of calcu-
lus ................. 45.0 10.0
Surg. Anes.
Excision
3515
3517
8.0
7.0
Incision
3541
9.0
3544
7.0
Excision
T
3550
T
3551
3552
Repair
4.0
T
3565
Incision
3571
3573
17.0
3575
12.0
3578
3588
12.0
3590
Cholecystectomy ........ 55.0 10.0
with open exploration of
common duct ......... 65.0 12.0
Pancreatotomy for drainage
of pancreatitis .......... 60.0 11.0
Removal of calculus ...... 60.0 12.0
Pancreatectomy - subtotal
(simple) .... .. ... 70.0 12.0
subtotal (Whipple type) ... 100.0 17. 0
total ............... 80.0 13.0
Marsupialization of cyst of
pancreas ............. 60.0 12.0
Exploratory laparotomy:
exploratory celiotomy ..... 35.0 7. 0
Drainage of peritoneal
abscess or localized
peritonitis exclusive of
appendical abscess ....... 40.0 7.0
Subdiaphragmatic or sub-
phrenic abscess, one or two
stages ............... 50.0 10.0
Retroperitoneal abscess ... 40.0 9.0
Peritoneocentesis: abdominal
paracentesis, initial ..... 4.0
subsequent ........... 2.0
Endoscopy
3595 Peritoneoscopy ......... 15.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Introduction
3611 Pneumoperitoneum: intra-
peritoneal injection of air,
Surg. Anes.
initial : ................ 3.0
3612 subsequent .... ... 2.0
3614 Retroperitoneal insufflation of
air .................. 4.0
Repair
When bilateral hernia is presentonday
of surgical repair or when one is con-
sidered potential for surgical repair,
postponement of surgical repair of
companion potential hernia or hernia
under three months will be considered
a bilateral procedure for this schedule
as if performed on the same day as one
herniorrhaphy was performed.
HERNIOPLASTY: HERNIORRHAPHY:
HERNIOTOMY
3631 Inguinal, unilateral ...... 30.0 6.0
3632 with appendectomy ..... 40.0 8.0
3633 with orchiectomy ...... 30.0 7. 0
3634 with excision of hydrocele 40.0 7.0
3635 recurrent ........... 40.0 8.0
3638 Inguinal, bilateral ....... 40.0 8.0
3640 with appendectomy ..... 50.0 10. 0
3641 with orchiectomy ...... 45.0 9.0
3642 with excision of hydrocele 50.0 10. 0
3643 recurrent . ......... 50.0 10.0
3646 Femoral, unilateral...... 30.0 6.0
3647 with appendectomy ..... 40.0 8.0
3651 recurrent ........... 40.0 8.0
3654 Femoral, bilateral ...... 45.0 9.0
3658 recurrent ........... 50.0 10.0
3661 Ventral, incisional ...... 40.0 8.0
3662 recurrent ........... 40.0 9.0
3663 Epigastric ............ 30.0 8.0
3664 recurrent ........... 45.0 9.0
3665 Umbilical ............. 30.0 6.0
3667 Omphalocele.........by report T
3709 Diaphragmatic ......... 70.0 13.0
Suture
3734 Secondary suture of abdominal
wall for evisceration or disrup-
tion ... .... ........ 20.0 7.0
3735 Suture of ruptured diaphragm . 60. 0 13.0
? . . ?.. . ?
orm 785MGI
Incision
3802 Drainage of perirenal
abscess (independent pro-
Surg. Anes.
cedure) .... ... . 40.0 7.0
3806 Exploration with or without
nephrotomy .. .... 70.0 11.0
3808 Nephrostomy with drainage . 60.0 10.0
3811 Nephrolithotomy, removal of
calculus .............. 70.0 11.0
3813 Division or transection of
aberrant renal vessels (inde-
pendent procedure) ....... 60.0 11.0
3815 Pyelotomy with exploration. 65.0 11.0
3816 Pyelostomy with drainage. . 60.0 11.0
3817 Pyelolithotomy .......... 65.0 11. 0
Excision
*3820 Renal biopsy (by trochar or
needle) ............... 3.0
3821 Nephrectomy ........... 70.0 12. 0
3822 plus total ureterectomy . . 100.0 17.0
3824 partial ............. 70.0 12.0
3827 Excision of cyst of kidney .. 60.0 12. 0
3829 Aspiration or injections of
renal cyst or renal pelvis .. 10.0
Introduction
3830 Perirenal insufflation, uni-
lateral or bilateral ....... 10.0
Repair
3831 Pyeloplasty: plastic operation
on renal pelvis with or with-
out plastic operation on ureter 70. 0 13.0
3835 Nephropexy: fixation or sus-
pension of movable kidney
(independent procedure).... 60.0 11.0
Suture
3841 Nephrorrhaphy: suture of
kidney wound or injury..... 70.0 15.0
3845 Closure of nephrostomy,
pyelostomy or other renal
fistula (e. g.: renal colic fis-
tula) .. ... ...... 80.0 13.0
3846 Symphysiotomy for horse-
shoe kidney ............ 100.0 17.0
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
3847 Renal sympathectomy (inde-
pendent procedure)......... 60.0; 11.0
Incision
3851 Ureterotomy with exploration
or drainage (independent pro-
cedure) ................ 60.0 10.0
3857 Uretero lithotomy ......... 60.0 10.0
Excision.
3861 Ureterectomy, complete or
partial (independent procedure) 70. 0 13. 0
3867 Suprapubic excision (inde-
pendent procedure) ........ 50.0 9.0
Repair
3871 Ureteroplasty: plastic opera-
tion on ureter (stricture) .... 70.0 13. 0
3874 Ureteropyelostomy: anasto-
mosis of ureter and renal
pelvis ................. 70.0 13.0
3876 Ureterocystostomy: anasto-
mosis of ureter to bladder:
unilateral .............. 60.0 12.0
3877 bilateral ..... ......... 70.0 15.0
3880 Ureteroenterostomy:
anastomosis of ureter to
intestine, unilateral........ 70.0 13.0
3881 bilateral .... ......... 100.0 18.0
3884 Ureterostomy: transplanta-
tion of ureter to skin, uni-
lateral ................. 60.0 11.0
3885 bilateral .............. 80.0 13.0
Suture
3891 Ureterorrhaphy: suture of
ureter (independent proce-
dure) 70.0 11.0
3895 Closure of fistula of ureter... 80.0 13.0
Incision
3900 Puncture aspiration of bladder
by needle .............. 5.0
3901 Cystotomy with exploration or
fulguration .......... .. 60.0
3902 Puncture aspiration by trochar. 5.0
3906 Cystooty y vytth jgainage..... 4.0..0.
3907 Cystolitlmton'y0 ;,, . :. ! :.:'.."M.:j
3908 Drainage of pe!rivtsicccl Qr. ; ? i ;
?7.0?
.
.
0?
? a
..
, prevesical space AbaceSs .?. ' . MX, to. 00
Form 785MGI
Excision Surg. Anes.
3911 Cystectomy, partial ...... 60.0 12.0
3913 complete ............. 100.0 19.0
3918 Transurethral electrore-
section of vesical neck,
female .. ? ...... 40.0 7.0
3920 Excision of bladder diver-
ticulum (independent pro-
cedure) . ... ........ 70.0 12.0
3922 Excision of bladder tumor
(see 3901) .. ? .......... 60.0 10.0
3924 Transurethralresection of
bladder tumors ......... 50.0 10. 0
Endoscopy (independent procedure)
3931 Cystoscopy, diagnostic,
initial ............... 5.o 5.0
3932 subsequent ... ..... 3.0 T
3933 with biopsy, initial ...... 8.0 5. 0
3934 subsequent ......... 5.0 5.0
3935 with ureteral catheteriza-
tion, initial .......... 10.0 5.0
3936 subsequent .......... 5.0 5.0
3937 for stone removal, manipu-
lation, initial ......... 20.0 6.0
3938 subsequent ......... 15.0 6.0
3939 Ureteral meatotomy....... 20.0 6.0
3940 Cystoscopy with fulguration,
minor lesion of bladder .... 8.0 5. 0
3941 Cystoscopy with fulguration
of bladder tumor, initial ... 25.0 7.0
3942 subsequent .....I .. 15.0 7.0
3943 Cystoscopy with insertion of
radioactive substance with or
without biopsy or fulguration,
initial ............... 30.0 7. 0
3944 subsequent ........... 20.0 7.0
3945 Resection or fulguration of
ureterocele ..... ..... 20.0 7. 0
3947 Cystoscopic removal of
foreign body ............. 20.0 6.0
Destruction
3951 Litholapaxy: crushing of
calculus in bladder and re-
moval of fragments ....... 40.0 7.0
Suture
3961 Cystorrhaphy: suture of
bladder wound, injury or
rupture .. ............. 50.0 12.0
3965 Closure of vesicovaginal,
vesicouterine, or
vesicorectal fistula ....... 50.0 13.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Incision
3971 Urethrotomy, external (inde-
Surg. Anes.
pendent procedure) anterior .. 10.0 4.0
3973 perineal .............. 25.0 4. 0
3975 Urethrostomy: drainage by
fistulization (independent pro-
cedure) ......... ...... 25.0 5. 0
3977 Meatotomy: cutting ofdmeatus
(independent procedure) ..... 3.0 T
3978 Drainage of periurethral
abscess .............. . 5.0 4.0
(See Integumentary System)
3979 Drainage of perineal urinary
extravasation (independent
procedure) ............. 25.0 5.0
Excision
3981 Excision of urethral caruncle
or fulguration............ 7.0 4.0
3991 Excision of diverticulum of
urethra (independent proce-
dure) ................. 40.0 7.0
3994 Excision or fulguration of
urethral polyps .......... 5.0 4.0
Endoscopy
4000 Urethroscopy, diagnostic .... 5.0
4001 with removal of calculus or
foreign body ........... 20.0 4.0
4004 with internal urethrotomy . . 20.0 4.0
4006 with fulguration of posterior
urethra ....... 10.0 4. 0
4008 subsequent ............ 3.0 T
Repair
4011 Urethroplasty: plastic opera-
tion on urethra ........... 30.0
4019 Diversion of perineal urinary
extravasation with diversion of
urinary stream .......... 50.0
Suture
4021 Urethrorrhaphy: suture of
urethral wound or injury..... 50.0
4023 Closure of urethrostomy or
fistula of urethra (independent
procedure) ............. 30.0
4025 Closure of urethrovaginal
fistula ... ...
..?' ?? .ii . i . ~'+ 40? Q??
Manipulation ' . . . ? ?
*4031 Dilation of irethral ?ecrivtur' _ ? ?
by passage of sound, initial .. 3. 0
Form 785MGI -23-
*4033 Surg. Anes.
subsequent ........... 1.0
MALE GENITAL SYSTEM
Incision
*4101 Dorsal or lateral "slit" of
prepuce (independent proce-
dure) ................. 3.0
Excision
*4111 Biopsy of penis ........ 2.0 T
4114 Amputation of penis, partial . 40.0 8.0
4115 complete ...... . . . . ... 50.0 9. 0
4116 radical ..............100.0 17.0
4120 Local excision of lesion of
penis ..... 5.0
4122 Circumcision, newborn
(within 14 days) .......... 3.0
4123 under age 10 .......... 5.0 4.0
4125 age 1) or over ......... 8.0 4.0
4127 Excisior, (or fulguration) of
warts ................ 5.0 4.0
Repair
4131 Plastic operation on penis for
hypospadias, straightening of
chordee . 30.0 8.01
4132 Urethroplasty for hypospadias
(see 0260 to 0325).
4134 Plastic operation on penis for
injury .......... 50.0 10. 0
4135 for epispadias .........100.0 16.4)
4138 for urinary extravasation.. 30. 0 6. 0
7. 0
Excision
4141
10.0
4144
4146
10.0
8.0
Repair
4152
.9.0 s
.? ?
.
. S
4156
r
.
4157
Biopsy (independent proce-
dure)...... 10.0 4.0
Orchiectomy, simple, uni-
lateral . . . . . . . 20.0 5.0
radical, unilateral. or
bilateral, with retroperi-
toneal gland dissection ... 100.0 18.0
Reduction of torsion of testis
b
y
Or
of
surgical means .......
30.0
6. 0
chiopexy, with attachment
testis to thigh (Torek)....
50.0
10. 0
with detachment of testis
from thigh, second stage
(Torek) ..............
5.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
4158 one or more stages, with
hernia repair........... 40.0 8. 0
Incision
4161 Drainage of abscess of
epididymis .............. 5.0 4.0
Excision
4171 Biopsy of epididymis ....... 10.0 4.0
4174 Excision of spermatocele
without epididymectomy ..... 10.0 4.0
4176 Epididymectomy, unilateral .. 30. 0 6.0
4177 bilateral ............... 40.0 7.0
Repair
Epididymovasostomy (anastomosis of
epididymis to vas deferens)
4181 unilateral ........... 40.0 8.0
4182 bilateral ............ 50.0 10. 0
Incision
*4191 Puncture aspiration of hydrocele 2.0
*4192 subsequent ............. 1.0
4201 Excision of hydrocele, uni-
lateral ................ 20.0 5.0
4202 with hernia repair (see
Hernioplasty)
Incision
4211 Drainage of scrotal abscess .. 10. 0 4.0
4215 Removal of foreign body in
scrotum ............... 20.0 4. 0
Incision
4231 Vasotomy: division or tran-
section of vas (independent
procedure) .............. 10.0 4. 0
Excision
4241 Vasectomy, complete or
partial (independent proce-
dure) ................. 10.0 4.0
Repair
4251 Vasovasostgr y,.unilalerak. a..2Q.00 'a :T
4252 bilaterar.... :? :.. ? i ?~5. 0 ~T".:
4261 Ligation of vas (independent
procedure) .. . .. . ...... . . 5.0 4.0
-orm 785MGI -24-
Excision
Surg. Anes.
4271
Excision of hydrocele of
spermatic cord (independent
procedure), unilateral ..... 30.0
4272
bilateral ... .. .. 40.0
4275
Excision of varicocele (inde-
pendent procedure), unilateral
30. 0
4278
'xcision
with hernia repair......
SEMINAL VESICLES
40.0
5.0
7.0
5.0
7.0
4291 Vesiculectomy .......... 80.0 14.0
PROSTATE
Incision
4301 Prostatotomy: external
drainage of prostatic abscess 30. 0 7.0
4304 Prostatolithotomy: removal
of prostatic calculus (inde-
pendent procedure).:...... 70.0 11.0
*4305 Prostate - needle biopsy.... 2.0
Excision
4311 Prostatectomy, perineal,
subtotal ............... 70.0 12.0
4313 perineal, radical ....... 100.0 16.0
4316 suprapubic, one or two
stages .............. 70.0 11.0
4318 retropubic ........... 70.0 13.0
Endoscopy
4321 Transurethral electrore-
section of prostate, includ-
ing control of postoperative
bleeding, complete ....... 70.0 13.0
4323 partial, initial......... 40.0 9.0
4324 partial, subsequent ..... 30.0 7.0
Incision
4401 Episiotomy, nonobstetrical.. 7.0
*4403 Incision and drainage of
abscess of vulva ......... 2.0 T
*4405 Incision and drainage of
Bartholin's gland abscess,
unilateral .... .... ... 2.0 T
4411 Hymenotomy: incision of
hymen ................ 5.0 4.0
Excision
*4421 Biopsy of vulva ......... 2. 0 T
I Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
4423 Vulvectomy, complete ...... 40.0 8.0
4424 partial , ...... ..... 30.0 7.0
4425 radical, including regional
lymph nodes............ 80.0 16.0
4427 Local excision of lesion of
external female genita' organ
(see 0178 to 0190, 0260 to
0325).
4428 Clitoridotomy: circumcision,
female ......... ...... 7. 5 4. 0
4431 Hymenectomy: excision of
hymen .......... ...... 7.5 4.0
4433 Excision of cautery destruc-
tion of Bartholin's gland or
cyst .. ........ 12.0 5.0
4436 Excision or fulguration of
Skene's glands............ 5.0 4.0
Repair
4443 Plastic operation on urethral
sphincter, female (Kelly,
Kennedy) ..... ........ 20.0 5.0
4447 Repair of urethrocele, female
(independent procedure) ..... 20.0 5. 0
Suture
4451 Episiorrhaphy: suture of
recent injury of vulva....... 5. 0 4.0
Incision
4461 Colpotomy with exploration or
drainage of pelvic abscess ... 10.0 4. 0
*4463 Puncture and aspiration of
Douglas' cut de sac ........ 3.0
Excision
*4471 Biopsy of vagina (independent
procedure) .......... ... 3.0 T
4473 Colpectomy or colpocleisis,
complete; complete obliteration
of vagina ...... ....... 25.0 7.0
4474 partial (La Forte)........ 25.0 7.0
4476 Excision of vaginal cyst ..... 10.0 4. 0
4478 Excision of vaginal septum ... 10.0 4.0
Repair
4481 Colpoplasty, anterior vaginal
wall; repair of oysboeele?? . . s ..,
(independent pr?ce;u;eJ....:. 10Mb ': 1.0
4482 with repair of it hrcacele:. 0' : ' . 0 : ? :
4484 posterior vagtnatwalt" ' "~ ?
repair of rectocele (inde-
pendent procedure) ....... 25.0 6. 0
Form 785MGI -25-
4486 Colpoperineoplasty, posterior Surg. Anes.
vaginal wall; repair of
rectocele and perineoplasty;
pelvic floor repair ....... 25.0 7. 0
4488 Repair of cystocele, recto-
cele, and perineoplasty,
anterior and posterior
vaginal walls ... ..... 40.0 9.0
4491 with repair of urethrocele . 40.0 10. 0
4493 Repair of enterocele, with
or without associated re-
lated procedures, abdominal
approach .............. 40.0 10.0
4494 vaginal approach ....... 40.0 9. 0
4495 Colpopexy ... . 40.0 8.0
4497 Reconstruction of congenital
deformities of the vagina,
including vaginal atresia and
septate vagina ........... 40.0 10.0
Suture
4501 Colporrhaphy: suture of
recent injury of vagina (non-
obstetrical) ............ 10.0 T
4505 Colpoperineorrhaphy: suture
of recent injury of vagina
and perineim (nonobstetrical) 10. 0 T
4506 Closure of vaginal fistulae
(see Ureter, Bladder, Rec-
tum) .............. by report T
Manipulation
*4511 Dilation of vagina (under
anesthesia) ............ 3.0 T
Endoscopy
4521 Culdoscopy(independent
procedure) ............ 7.5
Incision
4531 Transection of fallopian tube,
unilateral or bilateral (inde-
pendent procedure), abdom-
inal approach ... ....... 40.0 7. 0
4532 vaginal approach ....... 40.0 7.0
Excision
4541 Salpingectomy, complete or
partial, unilateral or bi-
lateral (independent proce-
dure) ....... . ........ 40.0 8. 0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
4545 Salpingo-oophorectomy, com-
plete or partial, unilateralor
bilateral (independent pro-,
Surg. Anes,
cedure) , .. .... .... 40.0 9. 0
4551 Salpingoplasty for sterility,
unilateral or bilateral (inde-
pendent procedure) ..... . .. 40.0 T
Suture
4561
Ligation of fallopian tube,
unilateral or bilateral (inde-
pendent procedure) ........ 40.0 7. 0
Incision
4571 Drainage of ovarian cyst or
abscess, unilateral or bi-
lateral (independent proce-
dure) ................. 30.0 7.0
Excision
4581 Excision of ovarian cyst, uni-
lateral or bilateral (inde-
pendent procedure) ........ 40.0 8. 0
4583 Oophorectomy, unilateral or
bilateral (independent pro-
cedure), complete ........ 40.0 9.0
4585 partial ......... .... 40.0 8. 0
4591 Oophoroplasty, unilateral or
bilateral (independent pro-
cedure) ................ 40.0 9. 0
Excision
*4611 Biopsy of cervix or endo-
metrium (independent proce-
dure) ................. 2.0 T
HYSTERECTOMY -
4614 Hysteromyomectomy;
myomectomy; excision of
fibroid tumor of uterus...... 50.0 9. 0
4617 Panhysterectomy: total
hysterectomy (corpus and
cervix) .... .......... 60 0 11.0
4621 Supracervical hysterectomy:
subtotal hysterectomy ...... 50.0 9. 0
4624 Fundectomy, uterine: excision
of fundus of ute .uts ........ .. 450.0 A.?
4627 Radical hyster. .todi for. ' '
. .. ?? ?
cancer (Wertheim);.` ..; ~. .. . $0: 0' .11. 0
4631 Vaginal hysterMtothy, Mth o1-
without pelvic floor repair. . . . 60.0 11.0
Form, 785MGI
-26-
Surg. Anes.
4632 Removal of cervical stump .. 50.0 8. 0
4634 Trachelectomy: cervicec-
tomy: amputation of cervix
(independent procedure) . . . . 15.0 5.0
4637 Partial excision of cervix . . . 15.0 5. 0
*4641 Local excision of lesion of
cervix (cauterization or
conization) ... ..... 2.0 T
4644 Local excision of lesion of
cervix in conjunction with
dilation and curettage ..... 10.0 4.0
4646 Dilation and curettage of
uterus (independent proce-
dure), under general anes-
thesia ................ 10.0 4. 0
4647 for removal of uterine
polyps .............. 10.0 4.0
Introduction
4671 Insertion of radioactive sub-
stance into cervix, uterus or
both, with or without biopsy.
or dilation and curettage . . . 20. 0 4.0
4676 Injection of radiopaque con-
trast media ............ 3.0
HYSTEROPEXY -
4681 with ventrosuspension:
ventrofixation ......... 40.0 9. 0
4683 with presacral sympathec-
tomy with or without other
surgery ....... ..... 40.0 10.0
4685 with interposition opera-
tion (Watkins, Kennedy),
with or without pelvic
floor repair .......... 40.0 10.0
4687 with shortening of round
ligaments ............ 40.0 9.0
4690 with shortening of en-
dopelvic fascia: para-
metrial fixation (Man-
chester) with or without
pelvic floor repair . ..... 40.0 10. 0
4692 with shortening of sac-
routerine ligaments ..... 40.0 9. 0
4694 Hysterosalpingostomy:
anastomosis of tubes to
uterus .......... .... 40.0 10.0
4696 Tracheloplasty: plastic
repair of uterine cervix
(Emmett) .............. 15.0 5.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Suture
4701 Hystcrorrhaphy: suture of
ruptured uterus (non-
Surg. Anes.
obstetrical) .. ..... , . . 40.0 10.0
4705 Trachelorrhaphy: suture of
recent injury or laceration of
cervix (nonobstetrical)... by report T
Manipulation
4711 Dilation of cervix, instru-
mental (independent proce-
dure), in hospital . . . . . 5.0 4. 0
*4712 in office. . . 3.0
*4713 subsequent, office or hospi-
tal .................. 1.0
Incision
4720
Perineotomy with exploration,
drainage of abscess, etc. , , ,
Repair
4731
Perineoplasty: plastic repair
of perineum (independent
procedure) ... . . . . . . . . . . .
10.0
6.0
4734
in conjunction with vaginal
operations (see Vagina,
repair, 4481 to 4494).
4735
Repair of perineum and third
degree laceration of the rec-
Suture
tum ...................
30.0
9.0
4741
Perineorrhaphy: suture of
recent injury of perineum
(nonobstetrical)........ by report
T
4745
Closure of perineal fistula . . . 20.0
7.0
Surg. Anes.
4917 subtotal, or partial . .. . 50.0 10. 0
4924 total or subtotal, for malig-
nancy with neck dissection. 80.0 17. 0
4937 Recurrent thyroidectomy of
thyroid remnant .... 80.0 12.0
4941 Excision of thyroglossal ... .
duct, cyst or sinus .. . . . . . 40.0 9. 0
PARATHYROID, THYMUS, PITUITARY, PINEAL,
ADRENAL GLANDS AND CAROTID BODY
Excision
4971 Parathyroidectomy or ex-
ploration of parathyroid . . . . 60.0 11. 0
4972 Mediastinal exploration . . . . 100.0 20. 0
4988 Adrenalectomy .......... 70.0 18. 0
4993 Excision of carotid body
tumor .. ............. 100.0 18.0
STRUCTURES OVERLYING THE MENINGES,
BRAIN AND SPINAL CORD
Incision
CRANIOTOMY -
5001 Trephination (or burr holes),
exploratory, unilateral .... 35.0 10. 0
5008 Decompression, orbital, uni-
lateral or bilateral ....... 100.0 15. 0
5011 subtemporal .......... 60.0 12.0
5015 suboccipital .......... 60.0 13.0
5017 Osteoplastic crainotomy
(other than operation for
brain tumor) ........... 100.0 16. 0
Excision
5021
5025
5026
Incision
5027
4904
Incision and drainage of
thyroglossal cyst (infected),
5031
in hospital ............ . . 10.0
4.0
Excision
Repair
4911
Local excision of small cyst
5036
or adenoma of thy i 1,.. -.,ti ..;, Q. Q
S. 0.. .
5040
4914
Thyroidectomy, tQtaD of dam -; - - ; -. -:
plete ........I.;.-..;...; &L (I -12.D
Form 785MGI
Laminectomy .......... 80.0 15. 0
Hemilaminectomy, lumbar. . 70.0 15. 0
cervical ............. 80.0 17.0
dorsal ....... ..... 80.0 15.0
Cranioplasty: plastic opera-
tion on skull with bone graft
or metal or plastic plate . . . 80. 0
Repair of encephalocele .... 75.0 17. 0
Repair of meningocele
(spina bifida) ...... .... 70.0 17.0
Repair of meningomyelocele. 80.0 17.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
MENINGES AND MENINGEAL VESSELS
Incision Surg. Anes.
5051 Drainage of subdural, epidural
or subarachnoid space for
abscess or hematoma, cranial. 90.0 18.0
5054 spinal 90.0 15.0
*5057 Spinal puncture: lumbar punc-
ture (independent procedure),
initial,, diagnostic with
pressure readings......... 3. 0
*5060 Simple spinal puncture...... 2.0
*5062 Cisternal puncture (inde-
pendent procedure) ........ 3.0
5065 Drainage of lateral or sigmoid
sinus for phlebitis or throm-
bosis ................. 60.0 16. 0
Excision
5071 Excision of meningeal tumor,
cyst or aneurysm ......... 100.0 21.0
Introduction
5081 Pneumoencephalography
(independent procedure) ..... 15.0 T
5084 Myelography (independent
procedure)............... 10.0 T
5085 Discogram .... ......... 10.0 T
5087 Visualization of intracranial
aneurysm by intracarotid in-
jection of dye (independent pro-
cedure) with exposure of caro-
tid artery ............... 25.0 7. 0
5091 without exposure of carotid
artery ............... 15.0 T
Repair
5101 Graft of dura ... .... 80.0 18. 0
5105 Marsupialization of lesion of
meninges (cyst or abscess)... 90.0 19. 0
Incision
5127, Drainage of brain abscess,
primary tapping .......... 50.0 12. 0
5128 subsequent tapping in opera-
ting room ..... .... 25.0 7. 0
5129 subsequent tapping in hospi-
tal room or ward ........ 10.0
5133 Frontal lobotomy, bilateral by
craniotomy ................., 60,0. 19.6--
5134 unilateral by c1rani4tcln ... ; "40:0:" it. W.
5138 Tractotom y (m edu l'a," . : . : : : "
mesencephalon).'" .. ".'..Z00' 0" 21. M
5142 Ventricular tap ........... 35.0 7. 0
5145 Subdural tap, unilateral ..... 35.0 7. 0
Form 785MGT
Excision Surg. Anes.
5151 Excision of cortical scar ... 100.0 20. 0
5154 Excision of brain cyst,
neoplasm or abscess ..... 100.0 22. 0
5157 Excision of brain tissue;
topec tom y ............. 100.0 20.0
5161 Excision of choroid plexus . . 50.0 20. 0
5164 Excision of lobe of brain, . . . 100.0 24.0
Repair
5181 Ventriculocisternostomy by
catheter: Torkildsen-type
operation ..... ...... 90.0 18. 0
5185 Mars upialization of lesion
(cyst, abscess).......... 90.0 20.0
SPINAL CORD AND NERVE ROOTS
Incision
5207 Chordotomy: tractotomy or
division or transection of
nerve tracts in cord (cervi-
cal-dorsal) ............ 100.0 17. 0
5211 Rhizotomy: division or
transection of nerve roots... 80.0 1.5.0
5214 Decompression of spinal
cord (by removal of hema-
toma, bone fragments)..... 80.0 18.0
Excision
5221 Excision of lesion of spinal
cord (neoplasm, cyst) ..... 100.0 20. 0
PERIPHERAL NERVES,
CEREBRAL NERVES AND GANGLIA
Incision
NEUROTOMY: cutting, division or
transection of nerve
5240 Retrogasserian neurotomy:
transection of sensory root,
trigeminal nerve, transtem-
poral ................. 100.0 17.0
5243 posterior fossa ........ 100.0 17. 0
5245 intramedullary .... .... 100.0 19.0
5250 Transection of trigeminal
and glossopharyngeal
nerve ................ 100.0 17.0
5252 Transection of phrenic
nerves (phrenicotomy) ..... 15.0
5253 Phrenemphraxis: crushing . . 15. 0
? 5254 Transection of spinal nerves . 40: 0 9. 0
. : 5256 Transection of occipital
? nerve ................ 40.0 9.0
5258 Transection of vagus nerve;
vagotomy; vagectomy
(abdominal) ............ 45.0 9.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Surg. Anes.
5265 Transection of eighth cranial .
nerve (Meniere's syndrome) . 100. 0 17. 0
Excision
5270 Excision of peripheral
neuroma, digit . ........ 6.0 4. 0
5271 other superficial .. .... 10.0 4.0
5272 deep ......... . . 20.0 7.0
5273 Phrenicectomy: resection of
nerve ... .. .. .. 15.0 6.0
5277 Neurexeresis: avulsion of in-
fraorbital nerve ...... .. 15.0 6.0
5278 Obturator neurectomy, uni-
lateral ............. 30.0 7.0
5279 bilateral ... ... .. . 40.0 9. 0
5281 Phrenicoexeresis: avulsion of
phrenic nerve ....... ... 15.0 7.0
5282 Stoefel's neurectomy, uni-
lateral . . ............ . 30.0 8.0
5283 bilateral ....... . ...... 40.0 10.0
Introduction
*5290 Injection of alcohol (intra-
spinal, paravertebral or
paracranial), initial........ 5.0
*5291 subsequent . .. , .. 5.0
*5294 Injection of alcohol (second
and third divisions for
trigeminal neuralgia), initial . 7.5
Nerve Block
5298 Paravertebral block, lumbar
or thoracic . , .. 5. 0 5.0
5300 Sympathetic block (cervical) .. 5.0 5. 0
5302 Stellate ganglion ........ . . 5.0 5.0
5311 Brachial plexus block....... 5. 0 5. 0
5 312 Intercostal nerves ......... 2.5 2.5
5313 Lumbar, sacral and coccygeal
nerves ............... 5.0 5.0
5314 Pudendal nerve ........... 5.0 5. 0
5315 Splanchnic nerves ......... 5.0 5. 0
5316. Ilioinguinal and iliohypogastric
nerves ... . ....... . ..... 5.0 5.0
5317 Sciatic nerve ............ 3.0 3.0
5318 Phrenic nerve ......... 2.5 2.5
5319 Other peripheral nerve ..... 2.5 2.5
Repair
NEUROPLASTY: plastic r opaMM of . Derr ve? ? + ? ? # * ? ?
injury. ? ? ? ? w ? s ? w ? ?.
5320 Major nerve, upper or lower: ?
arm or leg, old injury, inctud '~ -
ing scar excisions, local ad-
vancements, etc. ......... 40.0 T
worm 785MGI
Surg. Anes.
5321 recent injury or transplant. 30.0 T
5322 lysis or freeing from scar
of intact nerve . , . .. 20.0 T
5340 Digital nerve, within digit -
suture, lysis or free from
scar (each additional, add
25%) ........, .. .... 15.0 T
5343 Sensory nerves, hand or foot
(excluding digits) - suture,
lysis or freeing from scar,
or transfer (each additional,
add 25%) , ... 20.0 T
5344 Motor branch, median or
ulnar nerve, new or old
injury ...... .. 30.0 T
5350 Neuroanastomosis of spinal
accessory-facial, hypo-
glossal-facial, spinal ac-
cessory-hypoglossal or
others unspecified . . ..... . 75.0 T
5371
Cervical, unilateral ......
60.0
5372
bilateral .... , .
80.0
5375
Cervicothoracic, unilateral .
60.0
5376
bilateral. . , .... . ..
90.0
5381
Lumbar, unilateral . . .....
50.0
5382
bilateral . ..... ,
75.0
5385
Splanchnicectomy, unilateral.
60.0
5386
bilateral .............
90.0
5390
Presacral neurectomy,
hypogastric plexus........
50.0
Incision
EYE
EYEBALL
5401
Goniotomy, primary ......
30.0
5402
secondary .............
20.0
VEGETATIVE NERVOUS SYSTEM
Excision
Sympathectomy:
Excision
5411 Enucleation of eyeball (bulb
or globe) , .. .. ..... 30.0
5412 with implantation of
prosthesis.. ..... 40.0
5413 with movable implant,
? primary ............. 50.0
?
w ?
5414 secondary ..... . . . . . 60.0
5417 Evisceration of eyeball .... 30.0
5418 with implantation in
scleral shell .... . ..... 50.0
14.0
17.0
14.0
17.0
10. 0
15.0
12.0
18.0
10.0
7. 0
7.0
8.0
9.0
10. 0
12.0
7.0
10.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
CORNEA
Incision Surg. Anes.
5441. Keratotomy, any type ...... 10.0
5443 Paraceatesis of cornea
(keratocentesis) .......... 10.0
*5445 Removal of foreign body from
surface of cornea ......... 1.5
*5447 with magnet .... ...... 3.0
*5448 under slit lamp . , ....... 3.0
Excision
5451 Keratectomy, partial....... 30.0 10.0
5452 complete ............. 40.0 10.0
5457 Pterygium .............. 20.0 7.0
Introduction
5461 Tattoo of cornea, mechanical
or chemical.... , .... . 30.0 10.0
*5465 Curettage and cauterization of
corneal ulcer . ......... 5.0
*5466 Iontophoresis of corneal ulcer. 5.0
Repair
5471 Keratoplasty: corneal trans-
plant, lamellar .......... 80.0 15.0
5472 partial or complete,
penetrating ............ 100.0 17.0
Suture
5481 Suture of perforated cornea .. 20.0 T
Incision
5491 Sclerotomy, operative incision,
with removal of intraocular
foreign body (with or without
magnet) ..... . ....... 50.0 10.0
5492 with removal ~of foreign
body from anterior cham-
ber (with or without mag-
net) .. ..... ...... 50.0 10.0
5493 Removal of intraocular foreign
body with magnet, without
operative incision .... ...... 30.0 8. 0
5495 Sclerotomy, posterior
(paracentesis)... ........ 30.0 8. 0
5496 Aspiration of anterior cham-
ber ... .. .............. 4.0
Excision ?? ?? ??? a
5501 Sclerectomy for g4auaornxl?
with scissors, puncshor ? ? a
trephination (Lagrange, l-o~tah, ?
?~ a? a
? ? a
a ?
a ? ?.?
Elliott) .. ... ..... ...... 80.0 14. 0
Form 785MGI
Surg. Anes.
5503 Scleral resection, full thick-
ness ................ 100.0 17.0
5 504 lamellar ............ 100.0 17.0
5505 subsequent ........... 50.0 17.0
Introduction
5511 Air injection into anterior
chamber for chronic glau-
coma ................ 15.0 T
5515 Irrigation and air injection
into anterior chamber for
.chronic glaucoma ........ 15.0 T
Incision
5531 Irldotomy ............. 20.0 7.0
5532 with transfixion of iris;
iris bombe ........... 20.0
Excision
5541 Excision of lesion of iris ... 50.0 9.0
5544 "Complete" iridectomy;
optical iridectomy; pre-
liminary iridectomy . . .... 40. 0 8. 0
5546 Peripheral iridectomy ..... 40.0 8. 0
Destruction
5551 Diathermy of the ciliary
body; cyclodiathermy ..... 30.0 8.0
5552 Iridodialysis - repair ..... 40. 0 9. 0
5553 Corelysis ............. 40.0 9.0
5554 Cyclodialysis ........... 30.0 8.0
Manipulation
5571 Iridotasis (iridencleisis):
stretching of iris (inde-
pendent procedure) ....... 40.0 8. 0
Incision
5601 Discission; needling of lens,
primary .............. 20.0 7.0
5602 secondary............ 10.0 7.0
Excision
5611 Extraction of lens, intracap-
sular or extracapsular, uni-
lateral ............... 70.0 12.0
;? 5616 Removal of dislocated lens . . 100.0 12.0
? ? a
? ?a
a ?
? Incision
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Excision
Repair
Su rg.
5701
5631
Reattachment of retina,
electracoagulation, initial.... 80. 0
15.0
5702
5632
subsequent ............ 40.0
17. 0
Examination
5703
5635
Funduscopic, under
5707
anesthesia .............. 4.0
4.0
5712
5717
Incision, excision and repair
5641 Myotomy, tenotomy, re-
cession, resection, advance-
ment or shortening of ocular
muscles for strabismus, one
or more stages, unilateral ... 50.0
5642 bilateral .. ........... 60.0
5643 One muscle, initial ........ 30.0
5646 subsequent ............ 20.0
5647 Muscle transplant ......... 70.0
Incision
5651 Orbitotomy with exploration .. 60.0
5652 with drainage of intraocular
abscess .. ......... 60.0
5653 with removal of intraorbital
foreign body ........... 60.0
5662 Excision of lesion of orbit,
benign or malignant ........ 60.0
5664 Exenteration or evisceration of
orbital contents with or without
graft .................. 100.0
Introduction
5671 Orbital injection of alcohol for
hemorrhagic glaucoma or in-
tractable pain ............ 10.0
Repair
5681 Plastic repair of orbit (see
0260 to 0325 and 0619, 0621,
0622).
Incision
*5691 Blepharotomy with drainage
of abscess of eyelid-, ...,?, R . * a, 0
? ? ? ? ? ? ?
*5692 with d rainag& of Ieihvmi*?nf
? . .
glands; hordecsluEn (seye) .... . Q ?
5697 Recession of levator
palpebrae muscle ......... 50.0
5698 Resection of levator palpebrae
muscle ................ 50.0
F orn, 785MGI
Repair
5721
8. 0
10.0
7.0
5723
7.0
12.0
5724
5725
12. 0
5726
12.0
*5728
12. 0
15. 0
Suture
5731
17.0
5734
5737
Surg. Anes.
Blepharectomy (see 0178 to
0190, 0260 to 0325).
incision or excision of
Meibomian glands
(chalazion), single ..... 5.0 T
multiple ........ . 6. 0 T
Excision of lesion of eyelid,
malignant (see 0178 to 0190,
0260 to 0325).
Epilation, electrolytic ..... 5.0
Excision of xanthoma (see
0178 to 0190, 0260 to 0325).
Blepharoplasty: plastic repair
of eyelid, with or without
graft, any type (see 0260 to
0325).
Canthoplasty: plastic repair
of canthus (see 0260 to 0319).
Plastic restoration of eyebrow
(by gra.`t) (see 0295 to 0325).
Tarsoplasty: plastic repair of
tarsal cartilage (see 0265 to
0267).
Reposition of ciliary base
(see 0260 to 0325).
Cautery puncture for en-
tropion or ectropion....... 5.0
Blepharorrhaphy: suture of
eyelid (see 0251 to 0252,
0265 to 0267).
Tarsorrhaphy: suture of
tarsal cartilage (see 0251 to
0252, 0265 to 0267).
Canthorrhaphy: suture of
palpebral fissure of canthus
(see 0251 to 0252, 0265 to
0267).
Incision
*5741 Removal of foreign body from
surface of conjunctiva ..... 1. 0
*5742 embedded in conjunctiva .. 2.0
*5743 Suture of conjunctiva ...... 3.0
..- . .
t * ? ?
? ? ? .
Excision
? .
5751
Biopsy of conjunctiva ... ..
5.0
*5753
Excision of lesion of con-.
10.0
junctiva: cyst ...........
5.0
5754
epithelioma (see 0178 to
10.0
0190, 0260 to 0325).
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
5755 nevus (see 0178 to 0190,
0260 to 0325).
Repair
Conjunctivoplasty:
5771
5773
5774
5775
5776
5777
Free graft of conjunctiva
(see 0295 to 0296).
of mucous membrane
(see 0295 to 0296).
Flap operation for corneal
ulcer ............ ? . .
Flap operation; "flapping" of
conjunctiva for perforating
injuries or operative wound ..
for laceration ..........
Repair of symblepharon with-
out graft (see 0178 to 0190,
0260 to 0276).
LACRIMAL TRACT
Incision
5801 Drainage of lacrimal gland
(abscess) ...............
5803 Drainage of lacrimal sac -
dacryocystotomy or
'dacryocystostomy . . ........
5804 Dacryocystomy or
dacryocystostomy, intranasal .
Excision
5811 Dacryoadenectomy: excision of
lacrimal gland ...........
5813 Dacryocystectomy: excision
of lacrimal sac ...........
5815 Excision of lacrimal gland
tumor .................
Surg. Anes.
15.0
15.0
7.5
10.0
T
7.5
T
20.0
T
50.0
10.0
50.0
10.0
50.0
10.0
10.0
T
50.0
10.0
Introduction
5821 Catheterization of lacri-
monasal duct, initial .......
Repair
5833 Dacryocystorhinostomy:
fistulization of lacrimal sac
into nasal cavity, with or
without anterior ethmoidec-
tomy (Toti)..............
*5835 Closure of punctum by
' . *.? A . , ? ? 1 . ? .. .
cautery . . . . . .. op.*
Manipulation ? ? ? ? ? ? ? ` ?
*5841 Dilation of punctum ........ 2.0
*5843 Probing of lacrimonasal duct,
initial ................. 3.0
785MGI
Surg. Antis.
*5844 subsequent ........... 1.5
Incision
*5901 Drainage of abscess of
auricle (see 0103). ... ... 2.0
*5903 Drainage of hematoma of
auricle .......... ... . 2.0
*5905 Drainage of abscess of
external auditory canal..... 2.0
Excision
5911 Biopsy of ear ........... 2.0
5914 Local destruction of lesion
of ear (see 0178).
5915 with plastic closure (see
0260 to 0325).
5917 Complete excision of ear:
amputation of ear ........ 20.0 T
5922 Excision of exostosis of
external auditory canal .... 20.0 T
5924 Radical excision of malig-
nant lesion of external audi-
tory canal ............. 60.0 12.0
Endoscopy
5933 Otoscopy with removal of
foreign body in external
auditory canal under general
anesthesia ............. 5.0 4.0
Repair
5941
5948
Suture
5951
Otoplasty: plastic operation
on ear (see 0260 to 0325).
Reconstruction of ear with
graft of skin plus cartilage,
bone or other implant (see
0260 to 0325, 0619 to 0622).
Otoplasty, of cartilage ("lop-
ear"), with or without re-
duction in size (unilateral) .. 40. 0
Otoplasty (bilateral)....... 60.0
Suture of wound or injury of
ear (see 0251 to 0252, 0265
to 0267).
Eustachian tube, catheteriza-
tion and insufflation ....... 1.5
8. 0
11.0
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
*5961 Myringotomy; tympanotomy;
plic otom y .............. 2.0
Excision Surg. Anes.
5971 Mastoidectomy, simple ..... 40.0 9.0
5975 radical ............... 60.0 12.0
*5982 Removal of middle ear polyp
by snare ............... 5.0
5983 in hospital ............ 10.0 4.0
5984 Ossiculectomy ........... 20.0 T
Repair
5991 Revision of radical mastoid
cavity ................. 60.0 12.0
5992 Tympanoplasty (to Include
complete mastoidectomy) .... 100.0 T
5993 Myringoplasty (ear drum
repair) .. ...... ........ 60.0 12.0
5995 Reconstruction of canal and
middle ear for agenesis (con-
genital atresia of ear canal) . . 100. 0 T
Suture Surg. Anes.
6001 Closure of fistula mastoid .. 20.0 7.
INTERNAL EAR
Incision
6011 Labyrinthotomy, any type... 80.0 14.0
Excision
6021 Labyrinthectomy ........ 80.0 14.0
Repair
6031 Fenestration of semicircular
canals . . . . . . . . . . . . . . . 100.0 15.0
6032 Revision of fenestration
operation ............. 60.0 12.0
6033 Stapes mobilization....... 60.0
a? ?? a?? a w y:? a a
? ? a a ?~? ? ?a ?+ a ?? ?
? a a ? ? ^ a ~+ ? a ? ? a
a ?? ? ? a a. - a a 4a
? a ? ? a a ? ? ?
Form 785MGI
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
1. The listed unit value for procedures indicated by an asterisk shall apply only to surgery. All other
unit values include two weeks' postoperative care.
2. Two or more procedures performed during the course of a single operation through the same
lr.cision, or in the same natural body orifice, or in the same operative field shall be considered
a one procedure with a value equal to the largest of the values for the respective procedures,
uirless otherwise specified in the schedule.
3. In case of multiple surgical procedures, in separate operative fields and separate incisions, 50
per cent of the allowance for the minor procedures will be paid in addition to the amount payable
for the major procedure, unless otherwise specified in the schedule.
4. The Association will determine a value consistent with values listed for a cutting procedure not
listed in the schedule - such determination in each case, to take into account the nature and com-
plexity of the procedure involved and the exceptions, limitations and exclusions of the policy
applicable.
5. In any event, the aggregate payment for all procedures shall not exceed the allowance indicated
for the procedure of highest unit value for any one period of disability.
6. Successive procedures shall be considered to have been performed. during one period of disability
unless:
(a) in the case of a protected person, the subsequent operation is performed after return to work
on full time or unless the subsequent operation is due to causes entirely unrelated to the
causes of the previous operation.
(b) in the case of a dependent, the subsequent operation is performed more than three months
after the previous operation or unless the subsequent operation is due to causes entirelyun-
related to the causes of the previous operation.
1. Anesthesia Service incorporates the customary preoperative and postoperative visits, the
administration of the anesthetic and the administration of fluids or blood incident to the anesthesia
or surgery.
2. Listed Anesthesia Service Fees are payable only when the anesthesia is personally administered
by a physician and surgeon who remains in constant attendance during the procedure for the sole
purpose of rendering such anesthesia service.
3. If the anesthesia is administered by the attending surgeon or his assistant, the fee shall be 50
per cent of the listed amount.
4. In procedures where no anesthesia unit is listed, if anesthesia service is required, the fee for
service is determined according to time.
5. In procedures where the anesthesia unit is listed as "T, " the fee for service is determined accord-
ing to time.
6. Anesthesia based on time starts with the beginning of anesthesia and ends when the anesthetistis
no longer in professional attendance (when the patient may safely be placed under customary post-
operative giilleiddr .
Form 785MGI -31+-
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
First half hour (or any fraction
thereof) ... ...... .. ... .......... 4.0
Third and fourth quarter hour (or major
fraction thereof) each . .. .. .......... 1.5
Each succeeding quarter hour (or major
fraction thereof) ....................... 1.0
7. SURGICAL CONDITIONS regarding multiple surgical procedures is equally applicable to anesthesia
procedures.
OBSTETRICAL BENEFITS. If a female protected person or a dependent wife, while insured under this
policy, shall have an obstetrical procedure performed by a physician or surgeon as a result of pregnancy,
including resulting childbirth or miscarriage, the Association will pay for the expense actually incurred,
but not to exceed the following limits:
Relative Value Units
Delivery of child or children ............... 16
Cesarean section ....................... 30
Miscarriage .......................... 10
The Association will also pay for charges made bya physician
or anesthetist for the administration of anesthetic during the
course of an Obstetrical Procedure, but not to exceed $20. 00
for any one pregnancy.
Obstetrical Benefits for the female protected person are not payable unless s:_1e is covered under a family
enrollment.
PART C.
MAJOR MEDICAL EXPENSE BENEFITS
The benefits for dependents provided under this MAJOR MEDICAL EXPENSE BENEFITS provision shall
be applicable only if the protected person is eligible for, has requested and is insured for such dependent
benefits.
If a protected person or an eligible dependent, because of accidental bodily injuries or sickness, shall,
while insured under this provision, incur for such injuries or sickness, "covered charges" (defined in the
paragraph entitled COVERED CHARGES) in excess of any amounts payable under PARTS A and B of Plan II
plus the Deductible Amount (defined in the paragraph entitled DEDUCTIBLE AMOUNT), the Association will
pay 80170 of such excess covered charges, but not to exceed, in the aggregate, the Maximum Payment (de-
fined in the paragraph entitled MAXIMUM PAYMENT).
DEDUCTIBLE AMOUNT. The Deductible Amount is $100.00 for each protected person and each dependent
for all accidents and sicknesses or any combination thereof and is applied but once each Calendar Year.
After benefits become payable and have been paid for a Calendar Year with respect to successive or con-
current accidents or sicknesses or any combination thereof, the further payment of benef its shall be subj ect
to reapplication of the Deductible Amount. However, if Covered Charges incurred during the last three
months of a Calendar Year are used to satisfy the Deductible Amount for such Calendar Year, they maybe
carried over and combined with subsequent Covered Charges to satisfy the Deductible Amount for the fol-
lowing Calendar YeaX, .. , f. f ... -
CALENDAR YEAR. ~- C'aleodar;Ygai *gin; Qn JaOuar; 1 of each year and ends on December 31 of that
same year. f ? ? 000 . . ? f go* ? .
MAXIMUM PAYMENT - The maximum aggregate benefits payable under this provision. The Maximum
Payment is, $10, 000.00 for all accidents or sicknesses or any combination thereof for each protected per-
son and dependent.
Form 785MG1A -35-
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
After a total of at least $1, 000. 00 has been pdid under this provision for expenses incurred by any one per-
son, effective the first of the subsequent Calendar Year and on the first of each Calendar Year thereafter,
$1, 000. 00 will be added to the balance of the Maximum Payment for which such person then qualifies until
the Maximum Payment is reinstated to the original amount of $10, 000. 00.
COVERED CHARGES. The covered charges referred to in this provision shall be those charges incurred
for the following services and supplies which are reasonably necessary for treatment of an injury or ill-
ness, and Which are not unreasonably priced or of a Luxury nature, as determined bythe charges generally
incurred for cases of comparable nature and severity in the particular geographical area concerned:
1. Covered Hospital Charges - those covered charges incurred for the following services, and
treatments and supplies which are recommended by the attending physician in the diagnosis and
treatment of an injury or illness:
(a) Hospital charges for room and board, excluding any charge in excess of $20. 00 for hospital
confinement in a private room.
(b) Hospital charges for drugs, medicines and other services and supplies, if used while confined
in the hospital as a resident patient.
(c) Hospital charges for outpatient services in connection with (1) a surgical operation or related
charges or (2).emergency treatment for accidental bodily injuries.
2. Covered Surgical Charges - those covered charges incurred for the following services:
(a) Charges made by a physician or surgeon for the performance of an. operation or the repair of
a dislocation or fracture (excluding assisting surgeons' charges).
(b) Charges for the services of a professional anesthetist, providing the anesthetist is not em-
ployed by a hospital which submits a charge to the protected person or dependent for his
services.
3. Other Covered Charges - those covered charges incurred for the following services and supplies
which are recommended by the attending physician in the diagnosis and treatment of an injury or
illness, and which are not included in the description of Covered Hospital Charges or Covered
Surgical Charges above:
(a) Other hospital charges incurred as an outpatient.
(b) Charges made by a physician for medical services, including his active services as an
assistant surgeon.
(c) Charges made by a registered graduate nurse or qualified physiotherapist, except for serv-
ices rendered by a person who ordinarily resides in the protected person's household or is a
member of his family.
(d) Charges for local professional ambulance service, and if the injuryor illness requires special
and unique hospital treatment, transportation within the United States or Canada to the nearest
hospital equipped to furnish the treatment not available in a local hospital, by professional
ambulance, railroad or commercial airlines on a regularly scheduled flight.
(e) Charges for the following additional services and supplies: drugs and medicines requiring
a physician's written prescription; diagnostic X-ray and laboratory service; oxygen and the
rental of equipment for its administration; blood or blood plasma and its administration;
radium, radioactive isotopes and X-ray therapy; casts, splints, braces, trusses and crutches;
rental of hospital type bed, wheel chair, iron lung or similar durable therapeutic equipment;
artificial limbs and eyes to replace natural limbs and eyes lost while insured under this pro-
vision; dental services rendered by a physician or dentist for the treatment of an injury to the
jaw or to natural teeth, including the initial replacement of these teeth and any necessary
dental X-rays resulting from an accident occurring while insured under this provision, pro-
vided the treatment is rendered within six months from the date of the accident.
NERVOUS OR MENTAL DISORDERS. If a protected person or an insured dependent shall incur covered
charges because of a nervous or mental disorder, the following conditions shall also apply:
1. Covered HoUpit?pJ C 4-geg, chz6r'ges6fQ c vulbive or shock treatment and charges for surgery
performed?ls a rp2Jt oj; a'n0rf6u9;oi;, e4i disorder shall be compensable in the same manner
and subject tT tjre s~me irnifht1olts 4J coi.difiDns as any other illness.
2. For all other ceveredechargC3 lncufr2Q?a3 a fesult of a nervous or mental disorder or com-
bination thereof, the Association, providing such charges are incurred while the protected per-
son or dependent is insured, will pay 50TO of covered charges in excess of the Deductible Amount;
Forni 785MGT -36-
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
provided, however, that the maximum payable for professional psychiatric treatment byaphysi-
cian at home, the office or the hospital shall not exceed $15. 00 per visit and not more than 50
visits during any one calendar year.
COMPLICATIONS OF PREGNANCY. Complications of pregnancy shall be defined to include only the fol-
lowing:
1. Surgical operations for extrauterine pregnancy;
2. Intra-abdominal surgery after termination of pregnancy;
3. Pernicious vomiting of pregnancy; and
4'. Toxemia with convulsions.
If a female protected person or a dependent wife shall incur covered charges because of complications of
pregnancy, as herein defined, the Association will pay benefits in the same manner and subject to the
same limitations and conditions as any other illness, provided:
1. If such female protected person or dependent wife is eligible for maternity benefits under any
other benefit provision of this group insurance plan for expenses incurred, payment for com-
plications of pregnancy under this provision shall be in lieu of such maternity benefits.
2. If such female protected person or insured dependent wife is not eligible for maternity benefits
under any other benefit provision of this group insurance plan for expenses incurred, the amount
of benefits payable for complications of pregnancy shall be reduced by $250. 00.
COMMON ACCIDENT. If a protected person and one or more dependents or if two or more dependents,
while insured under this provision, are injured in the same accident, all covered charges incurred as a
result of such accident n1ay be combined and only one Deductible Amount shall be charged, if applicable,
against such covered charges, regardless of the number of individuals involved. This combined Deductible
Amount shall also apply to future reapplications of the Deductible Amount for such common accident;
however, nothing herein shall be construed to reduce the Maximum Payment for each insured person.
EXCEPTIONS AND LIMITATIONS. This policy does not cover:
1. Dental services rendered by a physician or dentist except as specifically provided under "Other
Covered Charges;" or
2. Eye refractions or the fitting or cost of eyeglasses or hearing aids; or
3. Cosmetic surgery except for the repair of accidental injuries sustained while insured under this
policy; or
4. Alcoholism or drug addiction.; or
5. Pregnancy, including resulting childbirth, miscarriage or abortion, or resulting complications,
except as provided under the paragraph entitled COMPLICATIONS OF PREGNANCY and MATERNITY
BENEFITS and as provided under the Surgical Schedules for "Obstetrical Procedures;" or
6. Nervous or mental disorders under PART C of Plan II except as provided under the paragraph en-
titled NERVOUS OR MENTAL DISORDERS.
Covered Charges will be reduced by the amount of benefits payable or value of services provided (a) under
any other plan for which any employer of the protected person or dependent makes payroll deductions or
contributions, or (b) under any federal, state or other governmental program.
This provision is also. subject to the exceptions contained in the EXCLUSIONS AND LIMITATIONS section
of the General Provisions.
? a ? a ? a a? M? as ?
? * ? ? ? ? a a ? a a . a ? ?
w a? ? ? a a a a ? ? ?s
Form 785MGI -37-
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
SETTLEMENT OF CLAIMS
PAYMENT OF CLAIMS. All indemnities provided by this policy other than benefits, if any, for loss of time on
account of disability will be payable within sixty days after receipt of due proof.
If this policy includes indemnity for loss of time on account of disability, all accrued benefits payable for loss
of time will, subject to due proof of loss, be paid each two weeks during the period for which the indemnity is pay-
able hereunder, and any balance remaining unpaid at the end of such period will be paid immediately upon re-
ceipt of due proof.
If this policy includes indemnity for loss of life of a protected person, resulting from accidental bodily in-
juries, any such indemnity which may become payable shall be paid to the beneficiary designated by the protected
person or, if there is no beneficiary designated or surviving, to the estate of the protected person. All other
indemnities shall be payable to the protected person.
Consent of a protected person's beneficiary, if one be named, shall not be requisite to any change of bene-
ficiary, or to any changes in this policy.
If any benefits of this policy shall be payable to the estate of the protected person or to a protected person
or beneficiary who is a minor or otherwise not competent to give a valid release, the Association may pay to
the hospital, physician or surgeon, on whose charge or fee claim is based, any sums due for Hospital Expense
Benefits, Surgical Expense Benefits or Medical Expense Benefits toward satisfaction of any amounts still owed
such hospital, physician or surgeon, and any balance of such sums and any sums due for Accident and Sickness
Weekly Benefits may be paid, up to an amount not exceeding $1,000.00, to any relative by blood or connection
by marriage of the protected person or beneficiary who is deemed by the Association to be equitably entitled
thereto. Any payment made by the Association in good faith pursuant to this provision shall fully discharge the
Association to the extent of such payment.
MEDICAL EXAMINATION. The Association shall have the right, through its medical examiner, to examine
any protected person so often as it may reasonably require during the pendency of a claim hereunder, and the right
and opportunity to make an autopsy in case of death where it is not forbidden by law.
NOTICE AND PROOF OF CLAIMS. Written notice of injury or of sickness, for which claim is made, must
be given the Association at its Home Office in Omaha, Nebraska, within sixty days after the date of the acci-
dent or within sixty days after the commencement of the sickness. In event of accidental death, if covered by
this policy, written notice thereof must be given to the Association within twenty days after the date of death.
Proof of such injury or sickness must be furnished to the Association at its Home Office in Omaha, Nebraska,
within ninety days after the end of the period of disability for which claim is made. Failure to furnish notice or
proof within the required time shall not invalidate nor reduce any claim if it shall be shown that notice or proof
was given as soon as was reasonably possible.
The Association will furnish such forms as are usually furnished by it for filing proofs of loss. If such forms
are not so furnished before the expiration of fifteen days after the Association receives notice of any claim here-
under, the person making such claim shall be deemed to have complied with the requirements of the policy as to
proof of loss upon submitting within the time fixed herein for filing proofs of loss, written proof covering the
occurrence, character and extent of the loss for which claim is made.
LEGAL PROCEEDINGS. No action at law or in equity shall be brought for recovery under this policy prior to
the expiration of sixty days after proof of loss has been filed in accordance with the requirements of this policy
and no such action shall be brought at all unless brought within three years from the expiration of the time
within which proof of loss is required by this policy.
CONFORMITY WITH STATE STATUTES. Any provision of this policy which, on its effective ate, is in
conflict with the statutes of the state in which the Policyholder resides on such date is hereby men ed Jo con-
form to the minimum requirements of such statutes. ? ? ??
? ?
?
?
Form 701 MGM Page 5
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
 Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9
Approved For Release 2009/05/26: CIA-RDP68-0014OR000200180011-9