2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Surgical Procedures

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

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 66)
   
• Treatment of burns
   
• Male circumcision
   
• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and Prosthetic Devices, and Section 5(c), Other Hospital Services and Supplies, for our coverage for the device.
   
• 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

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
     
• 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

Note: 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.

Note: We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).

Note: 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.


Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.

Basic Option - You Pay
Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

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 service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)

Participating/Non-participating: You pay all charges

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

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges