Surgical Procedures

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
Surgical Procedures

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

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 59)
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.

You Pay
Preferred: 30% of the Plan allowance (deductible applies)

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

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

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 16 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

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

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.

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
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.

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 affirming surgeries specifically listed as covered)
Reversal of gender affirming surgery
Surgical procedures for the treatment of morbid obesity when performed outside a Blue Distinction Center

You Pay
All charges