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 69
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 69
Benefit Description
Oral and Maxillofacial Surgery (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Oral and Maxillofacial Surgery (cont.)
Not covered:
- Oral implants and transplants except for those required to treat accidental injuries as specifically described on page 68 and in Section 5(g)
- Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically described on page 68 and in Section 5(g)
- Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically described on page 68 and in Section 5(g)
- Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically described on page 68 and in Section 5(g)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Organ/Tissue Transplants
Prior approval requirements:
You must obtain prior approval (see page 23) from the Local Plan, for both the procedure and the facility, for the transplant procedures listed below. Prior approval is not required for transplants of corneal tissue.
Note: Refer to pages 21-22 for information about precertification of inpatient care.
Prior approval requirements:
You must obtain prior approval (see page 23) from the Local Plan, for both the procedure and the facility, for the transplant procedures listed below. Prior approval is not required for transplants of corneal tissue.
- Blood or marrow stem cell transplant procedures (Note: Pages 73-74 have additional requirements that apply to blood or marrow stem cell transplants that are covered only as part of a clinical trial.)
- Autologous pancreas islet cell transplant
- Heart transplant
- Implantation of an artificial heart as a bridge to transplant or destination therapy
- Heart-lung transplant
- Intestinal transplants (small intestine with or without other organs)
- Kidney
- Liver transplant
- Lung (single, double, or lobar) transplant
- Pancreas transplant
Note: Refer to pages 21-22 for information about precertification of inpatient care.
Covered organ/tissue transplants are listed on pages 70-71. Benefits are subject to medical necessity and experimental/investigational review, and to the prior approval requirements shown above.
Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.
Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s approved transplant programs.