Need Help? 4. Highmark Health Options may provide coverage under the medical-surgical benefits of the ompany's Medicaid products for medically necessary bariatric surgical procedures for patients who are 18 years of age or older and diagnosed with persistent morbid obesity for at least two years (24 months). In 2013, an estimated 179,000 bariatric surgeries were to be performed in the United States (Ponce, 2014). Supporting the health of Western New York. On the other hand, 68% to 85% of MWL patients who are post‐bariatric surgery desire body contouring surgery to remove a panniculus (Constantine et al., 2014). No guarantee can be made of the accuracy of this information which was compiled from public sources. Your needs all in one place. Association. 2020 Cardiac Surgery: Is the Procedure Medicare Inpatient Only or not? Our medical policies include evidence-based treatment guidelines. ENHANCED REVIEW ON CERTAIN PLANNED INPATIENT SURGERY REQUESTS Effective July 1, 2020, Highmark will perform an enhanced review on authorization requests . Bariatric surgery should be performed in appropriately selected patients by surgeons who are adequately trained and experienced in the specific techniques used and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery. Artificial Intervertebral Disc: Lumbar Spine. In 2013, an estimated 179,000 bariatric surgeries were to be performed in the United States (Ponce, 2014). Freestanding Ambulatory Surgery Center CPT CODE2 Description Nat Average Medicare . He is an advanced laparoscopic surgeon and a leader in bariatric surgery. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit www.highmarkbcbs.com or call 1-888-510-1084. The SBC shows you how you and the would In order to be approved by Highmark Health for bariatric surgery in the United States, you must meet the following criteria: Be age 18 years or older. Conemaugh Health System is proud to be recognized by Highmark Blue Cross Blue Shield for meeting the robust selection criteria for spine surgery set by the Blue Distinction Specialty Care program. Medical Policies. We do so by offering health plans that provide reliable coverage to Western New Yorkers and by supporting the organizations and individuals who work . Medical decisions relative to medical technologies are to be made strictly by members/patients in consultation with their health . The SBC shows you how you and the plan would share the cost for covered health care services. INPATIENT FACILITY DRG Description* Average Length of Stay (Days)5 National Average DRG Payment5 Inpatient Facility 987 Non-extensive O.R. Community Blue Medicare PPO is a Medicare Advantage Preferred-Provider Organization plan that gives you coverage for every need— health, prescription drugs, routine dental, vision, hearing, and preventive care. New mask policy at AHN facilities. Highmark Health's policy on weight loss surgery also apply to their subsidiary insurance companies, including: Read . Gender Affirmation Surgery. procedure unrelated to principal diagnosis with MCC 10.5 $20,881 988 Non-extensive O.R. Your Anthem Blue Cross insurance policy covers weight loss surgery unless it states specifically that it excludes it. See how Allegheny Health Network and Highmark have dedicated themselves to bringing cutting-edge facilities and affordable care to western . Font size dropdown. What to Expect During Bariatric Surgery Life After Weight Loss Surgery Surgery . Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its . Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. That's why when you choose PPO BlueSM from Highmark Blue Cross Blue Shield Delaware, you get a plan that's simple to understand, easy to use, and easy to love. This will depend on the type of policy you have purchased. Nearly all plans cover obesity screening, behavioral counseling and nutritional screening and counseling as a standard. With Highmark, you get access to . Pharmacy and Prescription Plans. Many patients who have inadequate or no insurance coverage for weight loss . Blue Shield of California Reproduction without authorization from 601 12th Street, Oakland, CA 94607 Blue Shield of California is prohibited Medical Policy An i ndependent m ember of the Blue Shield Association in the Pre 7.01.47 Bariatric Surgery Original Policy Date: April 14, 1970 Effective Date: May 1, 2022 Section: 7.0 Surgery Page: Page 1 . They don't guarantee results or outcomes. • If individual has not had bariatric surgery, the member must have maintained a stable . Medical Policies. The increased number of Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 08/01/2020 - 07/31/2021 Highmark Blue Cross Blue Shield: PPO Blue Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. 2020 Bariatric Reimbursement Fact Sheet . Bariatric Product Reviews Featured Products Premier Protein Winter Mint Chocolate Shake PatchMD MultiVitamin Patches Community Popular Forums Bariatric Surgery Discussion Duodenal Switch (DS) Roux-en-Y (RNY) Vertical Sleeve (VSG) Bariatric Surgery in Mexico Ontario Canada See more forums Members Before & After Photos Member Photos Find Members . Step 1: Determine whether prior authorization is needed. The American Society of Metabolic and Bariatric Surgeons (ASMBS; Pratt et al., 2018), classifies severe obesity in adolescents as follows: Class II obesity - 120% of the 95 th percentile height, or an absolute BMI of 35-39.9 kg/m 2 , whichever is lower* Class III obesity - 140% of the 95 th percentile height, or an absolute BMI of >40 kg/m 2 This Coverage Policy addresses bariatric surgery and procedures for the treatment of morbid obesity. CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B (CMS-1715-F); Addendum B. For specialized services administered by independent companies on behalf of Capital Blue Cross: Behavioral health services. plan. The medical director of Arkansas Blue Cross and Blue Shield has established specific coverage policies addressing certain medical procedures or technologies. Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer. Coverage for bariatric surgery or revision of a bariatric surgery procedure varies across plans and may be governed by state mandates. Disclaimer: This is not the CMS Inpatient Only Procedure List (Annual OPPS Addendum E). procedure unrelated to principal diagnosis with CC 5.7 $ 10,763 989 Nonextensive O.R. NOTE: Information about the cost of this plan (called the premium) will be provided separately. Community Blue Medicare PPO includes a high value network of select providers, PLUS an enhanced service model to assist in finding . It's about peace of mind. Admission: Notify Blue Cross about all planned and unplanned admissions. itself. Highmark's medical policy guidelines address both clinical and claim payment reimbursement issues. Blue Cross Blue Shield Of Michigan Pre-Approval Requirements. The team at the NJ Bariatric Institute has helped many patients get their lives and their health back on track through bariatric surgery in New Jersey. Bariatric Surgery; Cardiac Care; Cellular Immunotherapy; Fertility Care; Gene Therapy; . Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/2020 - 05/31/2021 Highmark Blue Cross Blue Shield: PPO Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. procedure unrelated to principal diagnosis without CC/MCC 3.2 $ 7,218 Meadville, PA - Meadville Medical Center (MMC) is proud to be recognized by Highmark Blue Cross Blue Shield (BCBS) with a Blue Distinction® Centers+ (BDC+) for Maternity Care designation, as part of the Blue Distinction Specialty Care program. However, an exclusion of weight loss surgery from your BCBS plan should not discourage you from exploring various low cost self-pay options. (eel) High Tech Radiology including Cardiac Imaging and Radiation Oncology. Each month, our Medical Policy Group meets to review the policies for a specific specialty. Coverage for services may vary for individual members based on the terms of their specific benefit plan and the specific facts of a particular situation. To find more information about Highmark's benefits and operating procedures, such as accessing the drug formulary or using network providers, We incorporate input from the Massachusetts . Cosmetic / Reconstructive Surgery. If you must submit a telephonic request, call the appropriate phone number below to reach Medical Management & Policy: Western Region: 1-800-547-3627. Community Blue Medicare PPO is a Medicare Advantage Preferred-Provider Organization plan that gives you coverage for every need— health, prescription drugs, routine dental, vision, hearing, and preventive care. For more information about your coverage, or . If a patient is less than 18 years of age, a letter . Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 - 12/31/2020 Highmark Blue Shield: PPO Blue Coverage for: Individual/Family Plan Type: PPO . 2020-2021 Benefit Guide Effective July 1, 2020 . Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. The SBC shows you how you and the . Open a PDF. 3 Blue Distinction Centers for Bariatric Surgery | Program Selection Criteria Cost Nationally consistent and objective approach for selecting BDC+ was used to address market and consumer demand for cost savings and affordable healthcare. At Highmark Blue Cross Blue Shield of Western New York, we've built our legacy around empowering our communities and helping you be your very best you. . Refer to the customer's benefit plan document for coverage details. Antigen Leukocyte Antibody Test. Dr. Christopher Sanders, General Surgery in Wilkes-Barre, PA. See Reviews & Make an Appointment! Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 - 12/31/2020 Highmark Blue Shield: PPO Blue Coverage for: Individual/Family Plan Type: HDHP . There are several factors that impact whether a service or procedure is covered under a member's benefit plan. You can review our medical policies online any time. Acupuncture and Auricular Electrostimulation. Some hospital admissions require plan approval and will be reviewed for medical necessity. Discrimination is Against the Law 2020 Policy Documents. These guidelines are the proprietary information of Highmark. QHP Small Group Actual Policy Documents; . Include medical records that support the need for inpatient care. The Summary of Benefits and Coverage (SBC) document will help you choose a health . All references to "Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health . On the other hand, 68% to 85% of MWL patients who are post‐bariatric surgery desire body contouring surgery to remove a panniculus (Constantine et al., 2014). I was wondering if my husband's insurance covers the lap band . These guidelines are the proprietary information of Highmark. Exceptions to the age requirement can be made for patients under 18 years old if a . We strive to offer our members the latest in proven medical technologies by reviewing current scientific evidence and considering expert physician opinion when we develop our medical policies. 2020-2021 Benefit Guide Effective July 1, 2020 . 2021-05-21. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. Policies are written to cover a given condition for the majority of people. These guidelines address hundreds of medical issues, including diagnostic and therapeutic procedures, injectable drugs, and durable medical equipment. Providers are responsible for providing . CPT . These policies may change to stay up to date with current research. Pharmacy Programs. Laboratory Services. Anthem Blue Cross Blue Shield ME 348,000 8/13/2020 link X X Blue Cross Blue Shield of North Dakota ND 347,000 1/4/2021 link X X X(13-18 for . Artificial Intervertebral Disc: Cervical Spine. With Highmark, you get access to . The SBC shows you how you and the would licensees of the Blue Cross and Blue Shield Association. Blue Distinction Centers are nationally designated health care facilities that show a . You can also view the retired medical policies . Together, the Board of Pensions and Highmark partner to serve the Presbyterian Church (U.S.A.) congregations, agencies, and mid councils as well as affiliated employers. I realize all policies are different but with regards to your post, I have BCBS and in asking if they cover the sleeve, found out that they do not cover the sleeve but they DO cover the "Longitudinal Sleeve Gastrectomy".. 7.01.53. Charleston Area Medical Center is proud to be recognized by Highmark Blue Cross Blue Shield West Virginia with a Blue Distinction ® Centers (BDC) for Maternity Care designation, as part of the Blue Distinction Specialty Care program. Does Highmark Health Insurance cover weight loss surgery? Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. An Independent Licensee of the Blue Cross and Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in 21 counties in central Pennsylvania and 13 counties in northeastern New York. . Blue Distinction Centers for Substance Use Treatment and Recovery aims to improve patient outcomes and value by focusing on providers across the full continuum of care who deliver and facilitate treatment for substance use disorder, including opioid use disorder. We know choosing coverage is about more than just your health care. See answer (1) Best Answer. claims Doctors Forms ID Card claims Doctors Forms ID Card How We Serve Together. 9/8/20 Specialty Matched Consultant Advisory Panel review 8/19/2020. These guidelines address hundreds of medical issues, including diagnostic and therapeutic procedures, injectable drugs, and durable medical equipment. plan. All MPFS Fee Schedules calculated using CF of $36.0896 effective January 2020. It's about peace of mind. BARIATRIC SURGERY COVERAGE POLICIES -BLUE CROSS BLUE SHIELD COMPANIES Legend Independent Blues . Working with Dr. Sankar and PPG Health, Dr.Carlton . Blue Distinction Centers are nationally designated healthcare facilities that show a commitment to . or 100% over ideal weight or a BMI of at least 40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea). The SBC shows you how you and the plan would Highmark retains the right to review and revise its medical policy guidelines at its sole discretion at any time without prior notice. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Each individual's unique clinical circumstances may be considered in light of current scientific literature. Yes, some Blue Cross Blue Shield plans may not cover bariatric surgery. Community Blue Medicare PPO includes a high value network of select providers, PLUS an enhanced service model to assist in finding . Medical policies are based on constantly changing medical science and Blue Cross reserves the right to review and update our policies as necessary. Select Language; Select Language; Check Application Status These documents are available to you as a . Coverage Policy . CY 2020 . Internal Medical Policy Committee 11-19-2020 Change in Title from Obesity to Bariatric Surgery. The purpose of a Coverage Policy is to inform members and their physicians why certain medical procedures may or may not be covered under Arkansas Blue Cross and Blue Shield health plans. CIGNA said bariatric surgery coverage is an option available under Cigna's group medical plans, and clients can choose to include it. Medical policies, which are based on the most current research available at the time of policy development, state whether a medical technology, procedure, drug or device is: Procedures and General Guidelines Policies, Procedures and General Guidelines; . Highmark's mission is to be the leading health and wellness company in the communities we serve. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. Aqueous Shunts and Stents for Glaucoma. Independence's Policy Bulletins should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical services/treatments and/or procedures. Get the most . We know choosing coverage is about more than just your health care. If you have prescription drug coverage through Blue Cross and Blue Shield of Illinois, learning about your drug benefits can help you and your doctor get the most from your prescription drug coverage. Alternative Medicine. For Medicare Advantage Members, call: FreedomBlue PPO: 1-866-588-6967. All references to "Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health . Acute hospital care. "It's been an honor to receive this distinction since 2012 for Conemaugh Memorial Medical Center's expertise in spine surgery," said Dr . Copy. In addition, Medicare may cover behavioral counseling for obesity services when billed by one of the provider specialty types listed above and furnished by auxiliary personnel Healthcare benefit programs issued or administered by Capital Blue Cross and/or its subsidiaries, Capital Advantage Insurance Company ®, Capital Advantage Assurance Company ® and Keystone Health Plan ® Central. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. This program will be available on January 1, 2020. 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