Reconstructive Surgery

2024 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
Reconstructive Surgery

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

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

Gender affirming surgical benefits are limited to the following:
- For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, facial gender affirming surgery (limited to forehead lengthening, cheek augmentation, rhinoplasty, jaw reshaping, chin contouring, Adam’s apple enhancement (thyroid cartilage enhancement or implant), pitch lowering masculinization voice surgery, cosmetic fillers, botulinum toxin, fat grafting, and liposuction), electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
- For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, breast augmentation, facial gender affirming surgery (limited to chondrolaryngoplasty, rhinoplasty, contouring or augmentation of the jaw, chin, and forehead; facelift, hair removal and transplantation, pitch raising surgery/Wendler glottoplasty, cosmetic fillers, botulinum toxin, fat grafting and liposuction), and electrolysis (hair removal at the covered operative site)

Notes:

Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.
Benefits are not available for repeat or revision procedures unless they are determined to be medically necessary. Benefits are not available for gender affirming surgery for any condition other than gender dysphoria.
Gender affirming surgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The member must meet all requirements.
- Prior approval is obtained
- Member must be at least 16 years of age for mastectomy and 18 years of age for genital surgery at the time prior approval is requested and the treatment plan is submitted
- Diagnosis of gender dysphoria by a qualified healthcare professional with well-documented persistent gender incongruence, including documentation that other possible causes of gender incongruence have been excluded.
- Documentation of informed consent and fulfillment of the program’s criteria for gender affirming surgical treatment
- Member must meet the following criteria:
  - 6 months of continuous hormone therapy appropriate to the member’s gender identity (unless medically contraindicated; not required for mastectomy)
  - Must have a written psychological assessment from a qualified mental health professional documenting the diagnosis of persistent gender dysphoria with a well-documented persistent gender incongruence between the assigned gender and the experienced/expressed gender or some alternative gender, support of surgical procedure(s), and well-controlled physical and mental health conditions
  - Surgical treatment plan must include timing, technique, and duration of aftercare

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

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

Benefit Description

Reconstructive Surgery (cont.)

Not covered:

Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)
Surgeries related to sexual dysfunction or sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction)
Reversal of gender affirming surgery

You Pay
All charges