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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.
  • The $1,000 amount is not cumulative across categories. Each condition has its own $1,000 out-of-pocket limit.
  • Anesthesia and facility charges are reimbursed at usual levels.
Contact your field services representative (FSR) for more information.

To verify individual member benefits
Contact the Provider Helpline

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


Last modified 01/07/08