Reconstructive Surgery

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
Reconstructive Surgery

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

Benefit Description

Reconstructive Surgery
Reconstructive surgical procedures, limited to:

Surgery to correct a functional defect
Surgery to correct a congenital anomaly (See Section 10, page 129, for definition.)
Treatment to restore the mouth to a pre-cancer state
All stages of breast reconstruction surgery following a mastectomy, such as:
- Surgery to produce a symmetrical appearance of the patient’s breasts
- Treatment of any physical complications, such as lymphedemas
  Notes:
  - Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
  - If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
Surgery for placement of penile prostheses to treat erectile dysfunction

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

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

Benefit Description

Reconstructive Surgery (cont.)

Gender affirmingsurgical benefits are limited to the following:
- For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
- For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered operative site)

Notes:

Prior approval is required for gender affirmingsurgery. For more information about prior approval, please refer to page 20.
Benefits for gender affirmingsurgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender affirmingsurgery for any condition other than gender dysphoria.
Gender affirmingsurgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The member must meet all requirements.
- Prior approval is obtained
- Member must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
- Diagnosis of gender dysphoria by a qualified healthcare professional
  - New gender identity has been present for at least 24 continuous months
  - Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
  - Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
  - Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
- Member must meet the following criteria:
  - Living 12 months of continuous, full time, real life experience in the desired gender (including place of employment, family, social and community activities)
  - 12 months of continuous hormone therapy appropriate to the member’s gender identity (not required for mastectomy)
  - Two referral letters from qualified mental health professionals – one must be from a psychotherapist who has treated the member for a minimum of 12 months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery (one referral letter required for mastectomy)
  - If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

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

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

Benefit Description

Reconstructive Surgery (cont.)

Not covered:

Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)
Surgeries related to sexual dysfunction or sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction)
Reversal of gender affirmingsurgery

You Pay
All charges