CurrentBlue Cross Blue Shield - NevadaPolicy C-15003

Once-per-Lifetime Procedures

Defines reimbursement rules for procedures designated as once-per-lifetime for commercial professional claims and governs when such procedures will not be reimbursed by the health plan.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyOnce-per-Lifetime Procedures

Policy CodePolicy C-15003

Change TypeMaterial and non-material updates

Effective DateAug 13, 2025

Next Review DateN/A

Key ActionDo not bill for once-per-lifetime procedures if a historical claim with the same code or a code from the same code family exists unless an appropriate modifier or contractual mandate applies.

SourceLink

POLICY UPDATE CHANGES

Reinstated nonreimbursable language that disallows reimbursement for a code from the same code family which describe the same or similar type of service.

Updated Related Coding section to align code list with policy guidelines.

1pages (excerpt)

Nopolicy exemptions

Presentcode family list

Optum 2025coding ref

Once‑per‑Lifetime Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyOnce-per-Lifetime Procedures

Policy CodePolicy C-15003

Change TypeMaterial and non-material updates

Effective DateAug 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 reimbursement criteria

Reimbursement is denied for once‑per‑lifetime procedures in the following situations:

ANY of the following

ALL of the following
- A historical claim with the same procedure code is identified.
A historical claim with a code from the same code family that describes the same or similar type of service is identified.
There are no exemptions to this policy unless provider, state, or federal contracts and/or mandates indicate otherwise or the procedure is billed with an appropriate modifier.

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

Related Coding and Historical Claim Rules

Once-per-lifetime code familiesmixed

Once-per-lifetime procedure codes are arranged by code family in the Related Coding grid; inclusion/exclusion of a code does not guarantee reimbursement in all circumstances.

Historical claim rule

RuleNot reimbursed when a historical claim with the same procedure code is identified.

Same code familyNot reimbursed when a historical claim contains a code from the same code family that describes the same or similar type of service.

ExceptionsReimbursement may be allowed if provider, state, or federal contracts/mandates indicate otherwise.

Modifier allowanceOnce-per-lifetime procedures may be allowed when billed with an appropriate modifier.

Prior Authorization and Billing Modifiers

Prior Authorization

Prior authorization, medical necessity, modifier use, and denial risk for once‑per‑lifetime procedures

Services must meet authorization and medical necessity guidelines; once-per-lifetime procedures are not reimbursed when a historical claim with the same procedure code or a code from the same code family is identified, unless provider, state, or federal contracts/mandates indicate otherwise. The policy permits payment when the once-per-lifetime procedure is billed with an appropriate modifier.

Obtain prior authorization and confirm medical necessity per member benefit and state-specific requirements before performing procedures. [[citation]]
Check the member's claims history for any prior approved once-per-lifetime procedure with the same code or a code in the same code family; presence of such a historical claim will render the service nonreimbursable unless an exception applies. [[citation]]
If an exception applies under provider, state, or federal contracts/mandates, document the contractual basis and include it with the authorization/claim submission. [[citation]]
When applicable, append the appropriate modifier that justifies billing the once-per-lifetime procedure despite a historical claim, and include supporting documentation showing why the modifier applies. [[citation]]

Definitions Related to Once‑per‑Lifetime

Once-per-lifetime procedures — definition

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

ScopeApplies to once-per-lifetime procedures considered by the health plan when determining reimbursement eligibility.

Billing noteIneligible for reimbursement when a qualifying historical claim exists unless exceptions or appropriate modifiers apply.

Historical claim — definition

DefinitionA previously processed and approved claim by a previous carrier or affiliated health plan.

IncludesOnce-per-lifetime procedures that have been processed and approved by a prior carrier or affiliated plan.

Effect on reimbursementIf such a historical claim contains the same procedure code or a code from the same code family describing the same or similar service, the health plan will not reimburse the current claim unless exceptions apply.