In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Company Benefit Contracts.
Policy: 11.08.01f:Hair Transplants and Cranial Prostheses (Wigs)
Policy: 11.08.03j:Lipectomy and Liposuction
Policy: 11.08.04h:Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
Policy: 11.08.05g:Application and Removal of Tattoos
Policy: 11.08.06j:Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
Policy: 11.08.08g:Chemical Peels
Policy: 11.08.12h:Surgery for Gynecomastia
Policy: 11.08.13g:Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
Policy: 11.08.14j:Removal of Breast Implants
Policy: 11.08.15u:Reconstructive Breast Surgery