2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 21
Section 3. How You Get Care
Page 21
- Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
- 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 78 for information about the exception to this requirement.
- Cardiac rehabilitation
- Cochlear implants
- Residential treatment center care for any condition
Note: See pages 23-24 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
- Positron emission tomography (PET) scan
Note: High technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval.
- Magnetic resonance imaging (MRI)
- Specialty durable medical equipment (DME), rental or purchase, to include:
- Specialty hospital beds
- Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies
- Specialty hospital beds
- Transplants: Prior Approval is required for all transplants, except cornea and kidney. Prior approval is required for both the procedure and if benefits require, the transplant program; precertification is required for inpatient care.
- Blood or marrow stem cell transplants listed on pages 63-65 must be performed in a transplant program designated as a Blue Distinction Center for Transplants. See page 17 for more information about these types of programs.
Not every transplant program provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the transplant program is specifically designated as a Blue Distinction Center for Transplants for that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number appearing on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
- Clinical trials for certain blood or marrow stem cell transplants – See pages 64-65 for the list of conditions covered only in clinical trials.
- Contact us at the customer service phone number on the back of your ID card for information or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage determination.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a Blue Distinction Center for Transplants to treat your condition. If your physician has recommended you receive a transplant or that you participate in a transplant clinical trial, we encourage you to contact the Case Management Department at your Local Plan.