2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 21

 

  • Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
     
  • Genetic testing
     
  • Surgical services – The surgical services on the following list require prior approval and when care is provided in an inpatient setting, precertification is required for the hospital stay.
     
    • Procedures to treat severe obesity 

      Note: Benefits for the surgical treatment of severe obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed in our medical policy which can be found at www.fepblue.org/legal/policies-guidelines. Benefits are only available for the surgical treatment of severe obesity       when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) Surgery.
       
    • Breast reduction or augmentation not related to treatment of cancer
       
    • Gender affirming surgery – Prior to surgical treatment of gender dysphoria, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan.
       
    • Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures
       
    • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
       
    • Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation
       
    • Reconstructive surgery for conditions other than breast cancer
       
    • Rhinoplasty
       
    • Septoplasty
       
    • Varicose vein treatment
       
  • Proton beam therapy – Prior approval is required for all proton beam therapy services except for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas.
     
  • Stereotactic radiosurgery – Prior approval is required for all stereotactic radiosurgery except when related to the treatment of malignant neoplasms of the brain and of the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.  
     
  • Stereotactic body radiation therapy
     
  • Reproductive services – Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI)
     
  • Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
     
  • Hospice care – Prior approval is required for home hospice, continuous home hospice, or inpatient hospice care services. We will advise you which home hospice care agencies we have approved.
     
  • Cardiac rehabilitation
     
  • Cochlear implants
     
  • Residential treatment center care for any condition
     
  • Prosthetic devices (external), including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis

 

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