Bcbs federal medical policy for bariatric surgery

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.

• 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

• Roux-en-Y gastric bypass
  
• Laparoscopic adjustable gastric banding
  
• Sleeve gastrectomy
  
• Biliopancreatic bypass with duodenal switch

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.

• 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
    
  • 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: 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

  • 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 genderaffirmingsurgeries specifically listed as covered)
    
  • Reversal of gender affirming surgery

  Standard Option - You Pay
  All charges

  Basic Option - You Pay
  All charges