Benefits for certain surgeries
Benefits for these treatments and procedures are exceptions to our standard benefit coverage levels:
- When they are covered (and self-funded plans may not cover them at all), the patient will be required to pay 50% of the cost of professional services, up to $1,000 out-of-pocket per plan year per condition.
- The $1,000 amount is not cumulative across categories. Each condition has its own $1,000 out-of-pocket limit.
- After the patient has paid $1,000 per condition in a contract year, their plan will pay according to the schedule of benefits.
- Anesthesia and facility charges are reimbursed at usual levels.
Contact your provider account coordinator (PAC) for more information.
To verify individual member benefits
Contact the Provider Help Line. Medicare exception
The benefits in this chart do not apply to individually purchased Priority Health Medicare plans. However, some employer-sponsored Priority Health Medicare plans may offer these benefits. Call Priority Health Medicare Customer Service at 888 389-4869 for a patient's Medicare benefits.
| Treatment | Medical policy or other reference |
|---|
| Bariatric surgery |
Limited one per lifetime; Obesity - 91435 |
| Blepharoplasty of upper lids |
Blepharoptosis-brow ptosis repair - 91376 |
| Breast reduction |
Breast surgeries - 91545 |
| Hyperhidrosis treatment |
Hyperhidrosis - 91451 and Botulinum toxin - 91455 |
| Keloid scar treatment |
Facial scar revisions - 91442 |
Lipomas excision
|
All surgical services (CPT codes 10000-69999) billed with these diagnoses:
214.0, 214.1, 214.9 |
| Male gynecomastia surgical treatment |
Breast surgeries - 91545 |
| Panniculectomy |
Panniculectomy-abdominoplasty - 91444 |
| Port wine stain and hemangioma treatment |
Port wine stains and vascular malformation - 91413 |
| Rhinoplasty |
Septoplasty/rhinoplasty - 91506 |
| Scar revisions |
Facial scar revisions - 91442 |
| Sebhorrheic keratoses excision |
All surgical services (CPT codes 10000-69999) billed with these diagnoses:
702.11, 702.19
|
| Septorhinoplasty |
Septoplasty/rhinoplasty - 91506 |
| Skin tag excision |
11200, removal of skin tags, multiple fibrocutaneous tags, any area: up to and including 15 lesions
11201, removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions (list separately in addition to code for primary procedure) |
| Sleep apnea treatment |
Obstructive sleep apnea & upper airway resistance syndrome - 91333 |
| Varicose vein treatment |
Varicose vein treatment - 91326 |
| Vitiligo treatment |
All medicine services (CPT 90000 codes excluding E&M codes) with the diagnosis of 709.01; any J or Q code with that diagnosis |
