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 70
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 70
If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not apply and you may use any covered facility that performs the procedure. If Medicare offers an approved program for an anticipated organ transplant, but your facility is not approved by Medicare for the procedure, please contact your Local Plan at the customer service phone number on the back of your ID card.
Blood or marrow stem cell transplants are covered as shown on pages 71-75. Benefits are limited to the stages of the diagnoses listed.
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on pages 71-75, the medical necessity limitation is considered satisfied if the patient meets the staging description.
The blood or marrow stem cell transplants listed on pages 71-75 must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility. The transplant procedures listed on page 74 must be performed at a FACT-accredited facility. See page 19 for more information about these types of facilities.
Not every facility provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the facility is specifically designated or accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number listed on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
Note: Coverage for the blood or marrow stem cell transplants described on pages 71-72 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to pages 73-74 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Note: We provide enhanced benefits for covered transplant services performed at Blue Distinction Centers for Transplants (see page 76 for more information).
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on pages 71-75, the medical necessity limitation is considered satisfied if the patient meets the staging description.
The blood or marrow stem cell transplants listed on pages 71-75 must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility. The transplant procedures listed on page 74 must be performed at a FACT-accredited facility. See page 19 for more information about these types of facilities.
Not every facility provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Benefits are not provided for a covered transplant procedure unless the facility is specifically designated or accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number listed on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services.
Note: Coverage for the blood or marrow stem cell transplants described on pages 71-72 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to pages 73-74 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply.
Note: See page 145 for our coverage of other costs associated with clinical trials.
Note: We provide enhanced benefits for covered transplant services performed at Blue Distinction Centers for Transplants (see page 76 for more information).
Benefit Description
Organ/Tissue Transplants
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 corneal transplants 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.
Organ/Tissue Transplants
- Transplants of corneal tissue
- Heart transplant
- Heart-lung transplant
- Kidney transplant
- Liver transplant
- Pancreas transplant
- Combination liver-kidney transplant
- Combination pancreas-kidney transplant
- Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
- Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
- Single, double, or lobar lung transplant
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 corneal transplants 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.
Organ/Tissue Transplants - continued on next page