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 Helpline

Medicare exception
The benefits in this chart do not apply to individually purchased PriorityMedicare^SM plans. However, some employer-sponsored PriorityMedicare 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