Updates to Once in a Lifetime Procedure Limit Policy

Effective October 1, 2021, Blue Cross and Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for each “Once in a Lifetime” procedure group to only once during a member’s lifetime according to the criteria outlined in “Once in a Lifetime” policy. Based on human anatomy, some procedures can only be performed once in a member’s lifetime. This policy describes procedures that are only possible to perform once in a member’s lifetime, therefore, only reimbursed once in a member’s lifetime.

Each “Once in a Lifetime” procedure group will only be reimbursed once per member. “Once in a Lifetime” procedure groups may consist of one or more codes. There may be times when a “Once in a Lifetime” procedure is reported more than once, including, but not limited to, co-surgeons, team surgery, discontinued procedures, surgeries that require an assistant surgeon, laterality, or split surgical care. When it is appropriate to report a "Once in a Lifetime” code more than once, the "Once in a Lifetime” code must be reported with the appropriate modifier.

Applicable codes are for reference only and are not all inclusive. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross NC web site. They are listed in the Category Search on the Medical Policy search page.

For full details, tables and guidelines on reporting and reimbursement, please see the updated “Once in a Lifetime” policy.