Reconstructive Surgery

2024 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
Reconstructive Surgery

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.

Benefit Description

Reconstructive Surgery

Surgery to correct a functional defect
Surgery to correct a congenital anomaly
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
  
  Note: Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
  
  Note: 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

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 Section 3 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.

Participating/Non-participating: You pay all charges

Benefit Description

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)

Note: Prior approval is required for gender affirming surgery. For more information about prior approval, please refer to Section 3.

Note: 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 other covered surgeries 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
- Member must meet the following criteria:
  - 6 months of continuous hormone therapy appropriate to the member’s gender identity (unless medically contraindicated and they are not required for mastectomy)
  - Documentation of informed consent and fulfillment of the program’s criteria for gender affirming surgical treatment
  - 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

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 Section 3 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: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.

Participating/Non-participating: You pay all charges

Benefit Description

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

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges