Friday, April 12, 2024

Does Blue Cross Blue Shield Cover Knee Surgery

Services That Need Approval

Florida Blue Member Shares her Mayo Clinic Knee Replacement Story

Depending on what type of plan you have, we may need to review and approve some of your health care services before we cover them. We call this prior authorization.

If you need preapproval, your doctor or health care professional will request a review on your behalf. Once we get the request, well begin the review process. So, its important they send us all the materials we need for your review, up front.

If youre looking for more information about prescription drug prior authorization, read Why do I need prior authorization for a prescription drug?

There are four types of review for health care services:

  • Preservice non-urgent review: When you need to get a certain health care service, but it isnt urgent. It can take up to 15 days for us to make our decision. This is the most common type of review.
  • Preservice urgent review: When you need to get a certain health care service as soon as possible, but it isnt an emergency. It can take up to three days for us to make our decision.
  • Urgent concurrent review: When youre already getting care and you cant wait to get approval for it. This often happens with trips to the emergency room. It can take up to 24 hours for us to make our decision.
  • Postservice review: When youve already gotten the care you need and you request approval for it. It can take up to 30 days for us to make a decision.

If you disagree with our decision, you can appeal.

Here are some services that need approval. This is not a full list.

Blue Cross Blue Shield Gastric Sleeve

Blue Cross Blue Shield gastric sleeve is a covered procedure under many types of insurance plans for qualified individuals. Gastric sleeve is currently the most popular form of bariatric surgery with an excellent success rate.

Therefore, as long as you meet the eligibility conditions, you should be able to obtain approval from your insurance company without much difficulty.

  • Coverage can vary: Each Blue Cross and Blue Shield health plan can vary regarding which gastric sleeve surgery expenses are covered. Talk to your insurance agent to verify the available coverage for you by filling out the free, no-obligation verification form. This will give you clarity on actual amount of coverage.
  • Meet the conditions: The process to obtain Blue Cross Blue Shield gastric sleeve coverage will include determining whether your body mass index falls within the required range. The insurer may also require details of your non-surgical weight loss efforts and your psychiatric evaluation report.
  • Risk awareness: Insurance providers in many states will require your bariatric surgeon requesting Blue Cross Blue Shield gastric sleeve coverage to explain to you the risks and benefits involved. They may also have to conduct a dietary assessment and provide you nutrition counseling.

Related: How much does gastric sleeve cost?

Your Knee Replacement Surgery Classification

There are two types of knee replacement surgery classifications: Inpatient surgeries and outpatient surgeries.

Oftentimes, inpatient means youll have a hospital stay after surgery, and outpatient means youll be discharged the same day as your surgery. But that may not be how your insurance company classifies your surgery.

In fact, its very possible that a knee replacement surgery would be classified as an outpatient surgery. Many patients do go home the same day as their surgery if they meet certain criteria and their insurance covers it. But even if a patient spends a night in the hospital, its likely that their surgery will be considered outpatient. This can have an impact on the total amount youre responsible for.

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How Does Medicare Cover Knee Replacements

Getting a knee replaced requires surgery. And since Medicare only covers surgical procedures that are deemed medically necessary, your knee replacement surgery must be deemed medically necessary by your doctor for Medicare to cover it.

Which part of Medicare actually covers your surgery depends on what kind of surgery you get. If your knee surgery is in an inpatient procedure, Medicare Part A will provide coverage. If you get outpatient surgery, Medicare Part B would provide coverage. If you have a Medicare Advantage plan, your coverage may be different as well. Talk with your plan provider for specifics.2

Your costs will vary based on the type of procedure you need and your Medicare coverage. If Medicare covers your surgery, you still likely will have costs including a deductible and coinsurance.

Average Costs For Hyalgan With Medicare Drug Coverage1

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Medicare coverage for Hyalgan can vary. You should speak with your doctor and contact your Medicare plan carrier to learn more about how your Hyalgan treatment may be covered by your plan.

If your Hyalgan treatment is covered by Medicare Part B, you will typically be responsible for paying the Part B coinsurance or copayment after you meet the Part B deductible, which is $233 per year in 2022.

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Does Medical Pay For Hip Replacement

The cost of hip replacement can vary greatly. Hip replacement surgery can cost anywhere between $23,203 and $74,000, according to Healthcare Bluebook. Its possible that the cost of a hip replacement surgery ranges from $10,000 to $100,000, but Ive heard of a woman who went over that mark.

An artificial hip joint made of steel and titanium is used to replace the natural joint in hip replacement surgery. When it comes to hip replacement surgery, Medicare covers a variety of expenses. Beneficiaries are not required to pay the entire cost of this procedure, but may be required to do so in some cases. Medicare will cover the majority of the cost of hip replacement, but it does not cover the entire procedure. Beneficiaries are required to pay a set amount of money in addition to having to pay their share of health care costs. Beneficiaries may be able to pay some of their healthcare costs through Medicare Supplement plans. A Medicare-approved doctor and medical facility are also required for hip replacement patients.

Paying For A Knee Replacement Yourself

If you dont have insurance and will be paying for your knee replacement, its wise to research knee replacement costs. The United States is known for wide variation in healthcare costs. According to Guroo.com , the national average cost of knee replacement surgery in 2020 was about $37,300, including pre-surgery appointments and postoperative rehabilitation.

Your choice of hospital or operating facility can be the biggest factor in the cost of your knee replacement. There can be a significant variance in price estimates from one place to another. When you compare these prices, make sure you are comparing apples to apples. Find out if the price is for a complete bundle of all services or if it only includes certain fees. You need to know what your total cost will be and not just the hospital fee.

When pricing your surgery, make sure the hospital and doctor know you are a self-paying patient. Many providers offer a discount for people who are paying for their own healthcare. You have to ask for it because they typically do not mention this upfront. Find out if you can finance the cost or break your payments into chunks. You can also use FSA, HSA and HRA funds to help pay for surgery.

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Hyaluronic Acid Injections Are Fda

Hyaluronic acid injections have been FDA approved for many years as a treatment for knee osteoarthritis. But the American College of Rheumatology recommends against the use of hyaluronic acid in patients with hip osteoarthritis. Nevertheless, some doctors have been using it off-label as hip injections for their patients. For example, Blue Cross/Blue Shield medical insurance considers intra-articular injections of hyaluronic acid in any joint other than the knee to be investigational and not medically necessary. Researchers have studied the effectiveness of hyaluronic acid injections for the hip and the results were inconclusive.

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What Other Costs Should I Worry About

Federal Employees Under Blue Cross Blue Shield Need To Know This

After you are discharged from the hospital, you will still need to be vigilant in caring for your new knee. You will likely be prescribed medications for pain and to reduce the risk of infection and blood clots. It is also very common to need physical therapy or rehabilitation after surgery, which can be costly depending on your coverage. Always consult with your doctor and insurance provider to make sure you know exactly what coverage you have before your surgery.

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Register For A Webinar About Hyaluronic Acid Products For Knee Injections

As BCBS of Michigan communicated previously, starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider some hyaluronic acid drugs to be preferred or covered and others to be nonpreferred or noncovered. You can find the full details in the article titled Blue Cross and BCN to cover select hyaluronic acid products, starting Jan. 1 in the November 2019 issue of The Record.

BCBS is holding webinars to provide information about hyaluronic acid products for knee injections for Blue Cross PPO, Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

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Blue Cross Blue Shield Massachusetts Lasik Discount Program

Most large health insurance plans such as Blue Cross Blue Shield Massachusetts do not cover LASIK surgery. Blue Cross Blue Shield Massachusetts offers Blue365 its discount program. LASIK is considered an elective procedure and health insurance coverage of LASIK varies depending on whether dedicated monthly premium dollars go to cover the LASIK eye procedure. Today, typically the only organizations with medical insurance plans that cover LASIK eye surgery are specialty unions that self-insure and dedicate monthly premium dollars to the insurance fund. However, due to LASIK being the most popular elective surgery most plans like Blue Cross Blue Shield Massachusetts offer a value added LASIK program known as Blue365.

At QualSight, we give the best price LASIK surgery prices. Our members and customers save significant money compared to the overall national average LASIK eye surgery cost. Our dedicated Care Managers will explain the procedure types and costs so you can understand the differences in LASIK eye surgery procedures.

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Planned Orthopedic Procedures Including Knee And Hip Replacement Surgeries Are On The Rise In The Us

In 2017, spending on planned orthopedic procedures was 25 billions dollars. That figure rose 44 percent in the period from 2010 to 2017. 242 thousand adult BCBS members under the age of 65 had a planned knee or hip replacement in 2017. Quality is improving, but cost is on the rise. Planned knee surgeries increased 17 percent from 2010 to 2017 while planned hip surgeries increased 33 percent in the same period. The average cost for a knee or hip surgery increased by 6 percent and 5 percent, respectively. The inpatient cost for a knee surgery was $30,249 and $19,002 for outpatient. The inpatient cost for a hip surgery was $30,685 and $22,078 for outpatient. Complication rates decreased for both inpatient and outpatient procedures, by 29 percent and 23 percent, respectively, for knee surgeries, and by 32 percent and 36 percent, respectively, for hip surgeries.

Empower yourself and your family.

Use your health plan’s doctor and hospital finder tool. If you live in an area with high cost variation for knee and hip replacement surgeries, compare doctors and facilities in your network to uncover potential cost savings or a Blue Distinction Center near you.

Follow your doctor’s advice. While it’s important to ask questions and do additional research, work with your doctor to select a site of care the best meets your needs.

How Much Does Vision Coverage Cost With Blue Cross Blue Shield

What Bcbs Plan Covers Bariatric Surgery

The cost of vision coverage through Blue Cross Blue Shield will vary depending on location and plan selection.

As an example, Blue Cross Blue Shield of North Carolina offers two vision plan options. One costs $7.13 per month while the other costs $16.36 per month.1 In California, vision plans are available from Blue California for $6.90 or $12.90 per month.2

Each of the plan options in North Carolina and California feature their own cost requirements for deductibles, copayments and coinsurance, along with offering varying allowances or discounts for certain products and services.

The cost of a Medicare Advantage plan from Blue Cross Blue Shield will also vary according to location. The table below shows some different plan premiums for Blue Cross Blue Shield Medicare Advantage plans with vision coverage in three cities using the Medicare.gov plan finder tool.

Medicare Vision Coverage

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What You Should Know About Blue Cross Blue Shield And Hip Replacement Surgery

Hip replacement surgery is a common procedure that can help people with hip joint pain. The surgery involves replacing the damaged hip joint with an artificial hip joint. This can relieve pain and help improve mobility. Blue Cross Blue Shield is a health insurance company that provides coverage for hip replacement surgery. This means that if you have Blue Cross Blue Shield health insurance, your hip replacement surgery will be covered by your insurance policy.

Hip replacement surgery can be beneficial to the health and mobility of patients. Every year, over 400,000 of these procedures are performed in the United States. Hip replacement surgery is covered by both Medicare and Medicare Advantage plans. Deductibles and co-insurances will still exist. Hip replacement surgery can cost up to $112,000 in the United States. In general, Medicare pays surgeons an average of $1,3751,450 for this surgery. The deductible check is a tool that can be used to determine whether a person has met their deductible.

Traditional or minimally invasive surgery can be used by surgeons. The length of the incision is a big factor to take into account. It is common for people to spend between four and five days in the hospital following surgery. Recovery can take anywhere from three to six months. In most cases, Medicare will cover the procedure after the doctor confirms that it is necessary.

How Do You Get Coverage From Blue Cross Blue Shield

You will need to apply through your local Blue Cross Blue Shield or the one registered for your state.

From there you will need to enter personal information, including your Social Security Number and your income information.

Your monthly premiums will be determined using the information provided, and your coverage will begin once you pick a plan that is suitable for you and your family.

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Does Bluecross Blueshield Cover Lasik Tips

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Verify that your login information is correct in each field.

If you still have trouble logging in, click the Forgot Password? link and follow the steps to reset your password.

Does Anthem Blue Cross Cover Lap Band Surgery

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Yes, Anthem Blue Cross covers lap band surgery provided you fulfill the eligibility criteria for this weight loss procedure. Make sure to carefully go through your insurance policy document to know which expenses related to your lap band surgery are covered.

Its always a wise idea to call your insurer and ask them to verify your actual Anthem Blue Cross lap band surgery coverage for you.

  • Lap band is a less frequent weight loss procedure, and Anthem Blue Cross lap band coverage may require a surgeons recommendation.
  • The pre-approval criteria and actual lap band coverage may vary for each patient and for each Anthem Blue Cross insurance plan.
  • Apart from meeting the BMI eligibility requirements, you may have to submit a letter detailing your weight loss efforts in the last 5 years.
  • Your co-morbidities will be evaluated if your BMI is less than 40 before you get Anthem Blue Cross lap band surgery authorization.
  • Depending on your lap band coverage, you may have to undergo up to one year of medically supervised non-surgical weight loss program.
  • Lap band fills cost is included in your Anthem Blue Cross lap band coverage, if your prior lap band surgery met the required conditions.

Related: Medical financing

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Insurance Coverage For A Knee Replacement

Most health insurance plansincluding Medicare and Medicaidcover knee replacement surgery. If your insurance plan covers it, your doctor will need to establish that it is medically necessary. It can help to know exactly what your doctor must document to show this. Talk to your insurance provider and ask about your coverage. Find out if your insurance only covers certain types of knee implants. Ask if you need preauthorization or any other paperwork before starting treatment.

Health insurance, Medicare, and Medicaid typically cover:

  • An evaluation appointment with an orthopedic surgeon
  • Pre-surgery appointments including diagnostic studies and lab tests
  • The surgery including fees for the doctor, anesthesia, knee implant, and hospital or facility operating room
  • Postoperative hospitalization
  • Preparation of your home for postoperative recovery with safety bars and other medical equipment
  • Rehabilitation and physical therapy appointments

Make sure you understand any limits on your coverage.

Blue Shield Of California Dropping Viscosupplementation Coverage 6/1/18

In the past year, Blue Shield of California has begun the process of dropping their coverage of viscosupplements for osteoarthritis of the knee.

As of , patients covered under Blue Shield of California commercial health insurance, will no longer receive ANY coverage for viscosupplementation treatment for osteoarthritis of the knee. This change has been implemented based on scientific reviews and guidelines that have determined this method of treatment is not considered to be medically necessary. Medically necessary is defined by Medicare.gov as a healthcare service or supply needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

For those patients who have received an approved authorization for viscosupplementation:

  • Treatment plan will need to be completed prior to June 1st in order to be covered.

For those patients who have been prescribed a series of three viscosupplementation injections

  • All three treatments will need to be done prior to June 1st.

NOTE: It is anticipated that other health insurance plans may follow BSCs lead and also stop coverage of viscosupplementations. We will attempt to update our Blog with any new information. However, it is best to contact your health plan directly to confirm authorization approval for this type of treatment.

If you have any questions about treatment options, give us a call at 722-7038 and set up an appointment with your doctor.

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