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 58
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 58
Benefit Description
Surgical Procedures (cont.)
Notes:
Requirements for surgical treatment of morbid obesity:
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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 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 57) 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 41 and 44 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 86 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
- Diagnosis of morbid obesity (as defined on page 57) for a period of 1 year 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
- 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.
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Surgical Procedures - continued on next page