CurrentBlue Cross Blue Shield - MainePolicy C-15003

Once-per-Lifetime Procedures

Defines reimbursement rules for procedures that may be performed only once per patient and governs when such procedures are not reimbursable by the health plan; applies to professional claims under the payer's commercial reimbursement policies.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOnce-per-Lifetime Procedures

Policy CodePolicy C-15003

Change TypeCoding and operational updates (material change)

Effective Date08/13/2025

Next Review DateN/A

Key ActionDo not reimburse once-per-lifetime procedures when a historical claim with the same procedure code or a code from the same code family is identified unless contracts or mandates indicate otherwise.

SourceLink

POLICY UPDATE CHANGES

Added nonreimbursable language regarding code from the same code family which describe the same or similar type of service.

Updated coding grid.

Removed modifier 58 (effective 08/01/2018) and made minor administrative changes; expanded code list.

08/13/2025Last approval/effective date

noneExemptions

1Pages

Once-per-Lifetime Reimbursement Criteria

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOnce-per-Lifetime Procedures

Policy CodePolicy C-15003

Change TypeCoding and operational updates (material change)

Effective Date08/13/2025

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Once‑per‑lifetime procedures are defined as procedures that can be performed only once on an individual patient by a physician or other qualified healthcare provider based on clinical, anatomical, code description, or coding instructions.

Do not reimburse when ANY of the following are identified:

A historical claim with the same procedure code is identified.
Historical claim includes procedures processed and approved by a previous carrier or Elevance‑affiliated health plan.
A historical claim with a code from the same code family that describes the same or similar type of service is identified.

Exceptions — Allow when ANY of the following apply:

Provider, state, or federal contracts or mandates indicate the procedure should be allowed.
The procedure is billed with an appropriate modifier.

There are no general exemptions to this policy.

No other exemptions apply beyond the exceptions listed above.

Procedure Code Grid and Historical Claim Rules

Once-per-lifetime procedure code gridmixed

See attached coding grid listing once-per-lifetime procedure codes arranged by code family; inclusion/exclusion of code does not guarantee reimbursement.

Historical claim check (inv-03)

RuleDo not reimburse when a historical claim with the same procedure code is identified.

RuleDo not reimburse when a historical claim contains a code from the same code family that describes the same or similar type of service.

ExceptionAllow when billed with an appropriate modifier or when provider/state/federal contracts or mandates indicate otherwise.

Authorization and Billing Guidance

Prior Authorization

Authorization, historical-claim check, and modifier use for once‑per‑lifetime procedures

Services must meet authorization and medical necessity guidelines; once-per-lifetime procedures are not reimbursable when a historical claim with the same procedure code or a code from the same code family that describes the same or similar service is identified, unless provider, state, or federal contracts or mandates indicate otherwise. The plan may allow a once-per-lifetime procedure when billed with an appropriate modifier.

Verify member eligibility and obtain any required prior authorization per standard authorization procedures before performing the service.
Check the member’s claims history for any historical claim with the same procedure code or a code from the same code family; if such a historical claim exists, do not bill for reimbursement unless a contract/mandate overrides the policy.
If a one-time procedure is clinically indicated despite a historical claim, bill with the appropriate modifier if permitted by the plan and retain documentation supporting medical necessity and any contractual/mandate justification.

Definitions: Once-per-Lifetime Procedures

Once‑per‑lifetime procedures (inv-05)

DefinitionProcedures that can be performed only once on an individual patient by a physician or other qualified healthcare provider based on clinical, anatomical, code description, or coding instructions.

Non‑reimbursement conditionReimbursement is not allowed if a historical claim with the same procedure code exists.

Non‑reimbursement conditionReimbursement is not allowed if a historical claim with a code from the same code family describing the same or similar service exists.

Historical claim scopeIncludes once‑per‑lifetime procedures processed and approved by a previous carrier or Elevance‑affiliated health plan.