2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 20
 
  • Genetic testing for the diagnosis and/or management of an existing medical condition
Note: Necessary medical evidence for BRCA related genetic testing includes the results of genetic counseling.
 
  • Surgical services – The surgical services on the following list require prior approval and when care is provided in an inpatient setting, precertification is required for the hospital stay.
     
    • Procedures to treat morbid obesity (see page 60-61)
Note: Benefits for the surgical treatment of morbid obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed on page 61. Benefits are only available for the surgical treatment of morbid obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) surgery.

Note: See tables on page 22-23 for special situations when another payor is primary.

 
  • Breast reduction or augmentation not related to treatment of cancer
  • Gender reassignment surgery – Prior to surgical treatment of gender dysphoria, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan.

    Note: See tables on page 22-23 for special situations when another payor is primary.
     
  • Outpatient surgical correction of congenital anomalies (see definition on page 132)
     
  • Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures
     
  • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
     
  • Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation
     
  • Reconstructive surgery for conditions other than breast cancer
     
  • Rhinoplasty
     
  • Septoplasty
     
  • Varicose vein treatment
     
  • Outpatient intensity-modulated radiation therapy (IMRT) – Prior approval is required for all outpatient IMRT services except IMRT related to the treatment of head, neck, breast, prostate or anal cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
     
  • Hospice care – Prior approval is required for home hospice, continuous home hospice, or inpatient hospice care services. We will advise you which home hospice care agencies we have approved. See page 80 for information about the exception to this requirement.
     
  • Cardiac rehabilitation
     
  • Cochlear implants
     
  • Outpatient residential treatment center care for any condition

    Note: See tables on pages 22-23 for special situations when another payor is primary.
     
  • Prosthetic devices (external), including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis
     
  • Pulmonary rehabilitation
     
  • Radiology, high technology including:
     
    • Magnetic resonance imaging (MRI)
       
    • Computed tomography (CT) scan