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 65
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 65
Benefit Description
Surgical Procedures (cont.)
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
See page 63
Basic Option - You Pay
See page 63
Surgical Procedures (cont.)
- 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
- 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.
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
See page 63
Basic Option - You Pay
See page 63
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
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