Certain surgeries benefits & billing
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.
To verify individual member benefits
Call the Provider Helpline or email provider.services@priorityhealth.com.
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 |
