Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Bariatric surgery
The Plan covers BlueCard PPO providers Out-of-network providers
Medically necessary inpatient hospital or facility
services for bariatric surgery preauthorized by
Anthem BCBS:
• Semiprivate room and board and general
nursing care (private room is covered only
when medically necessary)
• Intensive care and other special care units
• Operating, recovery, and treatment rooms
• Anesthesia
• Prescription drugs and supplies used during a
covered hospital stay
• Lab and diagnostic imaging
Medically necessary outpatient hospital or facility
services for bariatric surgery preauthorized by
Anthem BCBS:
• Scheduled surgery or anesthesia
• Lab and diagnostic imaging
• All other eligible outpatient hospital care related to
bariatric surgery provided on the day of surgery
Other notes:
• Please see the “Notifcation requirements” section on
page 7�
• Prior authorization is required for bariatric
surgery procedures� Anthem BCBS requests prior
authorizations be submitted in writing to:
Anthem UM Services, Inc�
PO Box 7101
Indianapolis, IN 46207
• If you live more than 50 miles from a Blue Distinction
Center for Bariatric Surgery, please refer to the
“Transportation and lodging” section on page 36�
• For a list of Blue Distinction Centers for Bariatric
Surgery, call Customer Service or visit Anthem
BCBS’s website� Refer to the “Contacts” section on
page 1 for information�
• For pre- and postoperative bariatric services,
please refer to the “Hospital inpatient” section on
page 20, the “Hospital outpatient” section on
page 21, and the “Physician services” section on
page 30�
• For professional services related to eligible
bariatric surgery services, please refer to the
“Physician services” section on page 30�
You pay 20% after you satisfy
the deductible when you use
Blue Distinction Centers for
Bariatric Surgery�
No coverage for any other
BlueCard PPO provider�
You pay 20% after you satisfy
the deductible when you use
Blue Distinction Centers for
Bariatric Surgery�
No coverage for any other
BlueCard PPO provider�
No coverage�
No coverage�
• Blue Distinction Centers for Bariatric Surgery are
designated facilities within the participating Blue
Cross Blue Shield organization’s service areas that
have been selected after a rigorous evaluation
of clinical data that provided insight into the
facility’s structures, processes, and outcomes of
care� Nationally established evaluation criteria were
developed with input from medical experts and
organizations� These evaluation criteria support
the consistent, objective assessment of specialty
care capabilities� Blue Distinction Centers for
Bariatric Surgery meet stringent quality criteria, as
established by expert physician panels, surgeons,
behaviorists, and nutritionists� The national Blue
Distinction Centers for Bariatric Surgery have been
developed in conjunction with other Blue Cross
Blue Shield organizations and the Blue Cross Blue
Shield Association�
Not covered:
• Removal of excess skin after weight loss, regardless of
need, including but not limited to panniculectomy
• Repeat weight loss surgery, defned as any second
or subsequent procedure performed, regardless of
coverage at the time of the previous procedure
• All other weight loss related services, supplies,
or treatments
Anthem Blue Cross Blue Shield PPO Plan 13