2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 64
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 64
Benefit Description
Surgical Procedures (cont.)
Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on pages 64-65.
Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.
Note: Prior approval is required for surgery for morbid obesity. For more information about prior approval, please refer to page 22.
Standard Option - You Pay
See page 63
Basic Option - You Pay
See page 63
Surgical Procedures (cont.)
- 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. Benefits are available only for the following procedures:
- Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch
- Roux-en-Y gastric bypass
Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on pages 64-65.
Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.
Note: Prior approval is required for surgery for morbid obesity. For more information about prior approval, please refer to page 22.
- 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 above) 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 42 and 46 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 99 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 above) for a period of 1 year prior to surgery
Standard Option - You Pay
See page 63
Basic Option - You Pay
See page 63
Surgical Procedures - continued on next page