2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

Page 64
 
Benefit Description

Reconstructive Surgery (cont.)

Not covered:

 
  • Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)
     
  • Surgeries related to sexual dysfunction or sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction and gender reassignment surgeries specifically listed as covered)
     
  • Reversal of gender reassignment surgery

You Pay
All charges
 
Benefit Description

Oral and Maxillofacial Surgery

Oral surgical procedures when prior approved are limited to:

 
  • Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
     
  • Surgery needed to correct accidental injuries (see Definitions, page 131) to jaws, cheeks, lips, tongue, roof and floor of mouth
     
  • Excision of exostoses of jaws and hard palate
     
  • Incision and drainage of abscesses and cellulitis
     
  • Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
     
  • Reduction of dislocations and excision of temporomandibular joints
     
  • Removal of impacted teeth

Notes:
 
  • See page 20 for information regarding prior approval.
     
  • Prior approval is required for oral/maxillofacial surgery, except when related to an accidental injury and provided within 72 hours of the accident. For more information regarding the prior approval see page 19.
     
  • Call us at the customer service telephone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., oral surgery) you are scheduled to receive.

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description
Not covered:

 
  • Oral implants and transplants except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically described above and in Section 5(g)
     
  • Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically described above and in Section 5(g)

You Pay
All charges