Surgical Procedures

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

Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.

Benefit Description

Surgical Procedures
A comprehensive range of services, such as:

Operative procedures
Assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures
Treatment of fractures and dislocations, including casting
Normal pre- and post-operative care by the surgeon
Correction of amblyopia and strabismus
Colonoscopy, with or without biopsy

Note: Preventive care benefits apply to the professional charges for your first covered colonoscopy of the calendar year (see page 42). We provide benefits as described here for subsequent colonoscopy procedures performed by a professional provider in the same year.
Endoscopic procedures
Injections
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive Surgery on page 63)
Treatment of burns
Male circumcision
Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and Prosthetic Devices, and “Other hospital services and supplies” in Section 5(c), Inpatient Hospital, for our coverage for the device.
Gender reassignment surgical benefits are limited to the following:
- For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
- For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered operative site)

Notes:

Prior approval is required for gender reassignment surgery. For more information about prior approval, please refer to page 20.
Benefits for gender reassignment surgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender reassignment surgery for any condition other than gender dysphoria.
Gender reassignment surgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The member must meet all requirements.
- Prior approval is obtained
- Member must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
- Diagnosis of gender dysphoria by a qualified healthcare professional
  - New gender identity has been present for at least 24 continuous months
  - Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
  - Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
  - Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
- Member must meet the following criteria:
  - Living 12 months of continuous, full time, real life experience in the desired gender (including place of employment, family, social and community activities)
  - 12 months of continuous hormone therapy appropriate to the member’s gender identity
  - Two referral letters from qualified mental health professionals – one must be from a psychotherapist who has treated the member for a minimum of 12 months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery
  - If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges

Benefit Description
Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over and the procedure must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

Benefits are available only for the following procedures:
- Roux-en-Y
- Gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch

Notes:

Benefits for the surgical treatment of morbid obesity are subject to the requirements listed below.
When the procedures are performed during an inpatient admission, precertification is also required, see page 19 for more information.
Prior approval is required for outpatient surgery for morbid obesity. For more information about prior approval, please refer to page 20.

Requirements for surgical treatment of morbid obesity:

Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The member must meet all requirements.
- Diagnosis of morbid obesity (as defined on page 61) for a period of 1 year prior to surgery
- Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see pages 43 and 47 for our coverage of nutritional counseling services.)
- Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise
- Evidence that attempts at weight loss in the 1-year period prior to surgery have been ineffective
- Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 88 for our payment levels for mental health services)
- Member has not smoked in the 6 months prior to surgery
- Member has not been treated for substance use disorder for 1 year prior to surgery and there is no evidence of substance use disorder during the 1-year period prior to surgery
Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:
- All criteria listed above for the initial procedure must be met again, except when the subsequent surgery is necessary to treat a complication from the prior morbid obesity surgery.
- Previous surgery for morbid obesity was at least 2 years prior to repeat procedure
- Weight loss from the initial procedure was less than 50% of the member’s excess body weight at the time of the initial procedure
- Member complied with previously prescribed post-operative nutrition and exercise program
- Claims for the surgical treatment of morbid obesity must include documentation from the member’s provider(s) that all pre-surgical requirements have been met

Notes:

When multiple surgical procedures that add time or complexity to patient care are performed during the same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the primary procedure.
We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).
When unusual circumstances require the removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable.

You Pay
When performed in a Blue Distinction Center for Comprehensive Bariatric Surgery: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of the service.

Benefit Description
Not covered:

Reversal of voluntary sterilization
Services of a standby physician
Routine surgical treatment of conditions of the foot (See Section 5(a), Foot care.)
Cosmetic surgery
LASIK, INTACS, radial keratotomy, and other refractive surgery
Surgeries related to 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
Surgical procedures for the treatment of morbid obesity when performed outside a Blue Distinction Center

You Pay
All charges

List Item:
surgical
procedures
anesthesia
operation
operative
surgery
surgeons
fractures
dislocations
cast
pre-operation
pre-operative
post-operation
post-operative
amblyopia
lazy
eye
strabismus
crossed
colonoscopy
biopsy
endoscopy
endoscopic
injections
removal
tumor
cysts
cancer
correction
congenital
anomalies
burns
circumcision
prosthetic
devices
gender
reassigment
mastectomy
hystorectomy
vaginectomy
salpingo-oophorectomy
ovary
ovaries
fallopian
metoidioplasty
meta
neophallus
urethroplasty
urethra
scrotoplasty
scrotum
electrolysis
hair
testicular
erective
prosthesis
penectomy
penis
orchioctomy
testicles
vaginoplasty
clitoroplasty
labiaplasty
oophorectomy
orchi
orchidectomy
labia
clitoris
vagina
dysphoria
impairment
occupational
hormone
therapy
referrals
letters
morbid
obesity
BMI
Mass
Index
Roux-en-Y
RYBG
gastric
bypass
laparoscopic
adjustable
banding
band
sleeve
gastrectomy
stomach
biliopancreatic
duodenal
medically
supervised
nutritional
psychological
smoked
substance
prescribed
incidental
complexity
reversal
sterilization
cosmetic
lasic
intacs
radial
keratotomy
sexual
inadequacy