2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 59

 

Benefit Description

Reconstructive Surgery (cont.)
Notes:
 
  • 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.
     
  • We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).
     
  • 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.

You Pay
See previous page

 

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
     
  • Surgical procedures for the treatment of morbid obesity when performed outside a Blue Distinction Center


You Pay
All charges

 

Benefit Description

Reconstructive Surgery
Reconstructive surgical procedures, limited to:
 
  • Surgery to correct a functional defect
     
  • Surgery to correct a congenital anomaly (See Section 10, page 129, for definition.)
     
  • Treatment to restore the mouth to a pre-cancer state
     
  • All stages of breast reconstruction surgery following a mastectomy, such as:
     
    • Surgery to produce a symmetrical appearance of the patient’s breasts
       
    • Treatment of any physical complications, such as lymphedemas
      Notes:
       
      • Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
         
      • If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
         
  • Surgery for placement of penile prostheses to treat erectile dysfunction


You Pay
Preferred: 30% of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating): You pay all charges

 

Reconstructive Surgery - continued on next page

 

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