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 62
 
Benefit Description

Surgical Procedures (cont.)

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

You Pay
See previous page
 
Surgical Procedures - continued on next page