2023 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 63
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 63
Must be performed in a Preferred hospital by a Preferred provider:
Note: Refer to pages 19-22 for information about precertification of inpatient care.
- Autologous pancreas islet cell transplants
- Corneal tissue transplants
- Pediatric pancreas transplants
- Pediatric combination liver-kidney transplants
- Pediatric combination pancreas-kidney transplants
Note: Refer to pages 19-22 for information about precertification of inpatient care.
Blood or marrow stem cell transplants are covered as shown below and on pages 64-65. Benefits are limited to the stages of the diagnoses listed.
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on the following pages, the medical necessity limitation is considered satisfied if the patient meets the staging description.
Notes:
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on the following pages, the medical necessity limitation is considered satisfied if the patient meets the staging description.
Notes:
- Coverage for the blood or marrow stem cell transplants described below and on the top of page 65 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to the bottom of page 64 and the top of page 65 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply.
- See page 122 for our coverage of other costs associated with clinical trials.
The following transplants are only covered for the diagnosis indicated for the transplant procedure.
Benefits for Allogeneic blood or marrow stem cell transplants are only available for the diagnoses as indicated below:
Benefits for Allogeneic blood or marrow stem cell transplants are only available for the diagnoses as indicated below:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with poor response to therapy, short time to progression, transformed disease, or high risk disease
- Chronic myelogenous leukemia
- Hemoglobinopathy (i.e., sickle cell anemia, thalassemia major)
- High-risk neuroblastoma
- Hodgkin’s lymphoma
- Infantile malignant osteopetrosis
- Inherited metabolic disorders (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome and Maroteaux-Lamy syndrome variants)
- Marrow failure (i.e., severe or very severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure red cell aplasia, congenital thrombocytopenia)
- MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))
- Myelodysplasia/myelodysplastic syndromes (MDS)
- Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis)
- Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Paroxysmal Nocturnal Hemoglobinuria
- Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)