CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Procedure code billing statuses and prior authorization guidance (code list)

This list maps CPT and HCPCS codes to plan operational labels (MP Criteria, Unlisted, EIU, Non Covered), notes codes that may require prior authorization or recommended clinical review, and records code-specific add/retire effective dates (most codes effective on or before 2023-01-01 unless noted).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedure code billing statuses and prior authorization guidance (code list)

Policy CodePolicy N/A

Change TypeAdditions / reclassifications (MP Criteria, EIU, Non Covered) and date updates

Effective DateVaries by code (see code-level entries)

Next Review DateN/A

Key ActionFor codes labeled 'MP Criteria' or 'Unlisted', submit for Recommended Clinical Review to avoid post-service review and obtain prior authorization where required by the member's contract.

POLICY UPDATE CHANGES

Multiple Category III and other procedure/drug codes were added with specified effective dates (examples: many codes added effective 06/15/2023, 07/01/2023, 08/01/2023, 09/01/2023, 10/01/2023, 11/15/2023, 12/01/2023, and some with future dates such as 03/01/2024).

Several codes include retire effective dates (commonly 08/31/2023, 09/30/2023, 10/14/2023, 10/31/2023, 11/16/2023, 01/31/2024 or 02/01/2024) and some source rows contain typographical date errors or placeholder dates (e.g., 11/0/52023 or 12/31/2999).

Some codes were reclassified between 'MP Criteria' (requires recommended clinical review and may need PA) and 'EIU' (excluded/not reimbursed) across specified date ranges (examples: 0807T/0808T, various wound matrix/Q-code series).

Several monoclonal antibody–related codes (notably M0240–M0246 and Q0240–Q0245) were added effective 06/01/2023 and are marked EIU or Non Covered in the listing.

Coverage classification changes were applied to multiple wound matrix/skin substitute codes, with transitions from MP Criteria to EIU or Non Covered and add/retire effective dates (examples: Q4280–Q4284 series showing retire/add actions and reclassifications).

140+Procedure codes listed in this part

MultipleCodes with MP Criteria designation

SeveralCodes flagged EIU (not reimbursed)

SeveralUnlisted codes (may need review)

Coverage classifications and operational labels

Operational designations per code

Operational designations applied at the plan (policy) level. These labels indicate how procedure and supply codes are classified for review, coverage, and reimbursement workflows. Except as otherwise noted in the date column, codes listed are effective on or before January 1, 2023. Some codes include specific effective/retirement dates indicated in the per-code mapping.

MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service (retrospective) review. May require submission through Availity or utilization management processes. Codes with this designation remain candidates for clinical review and may require medical documentation to determine coverage.

Unlisted or Undefined: Procedures/services not specifically defined or classified by a standard code. These may be subject to contract or clinical review and require submission of operative reports, clinical notes, and pricing justification.

Prior Authorization may be required: Highlighted procedures/services in code groups may require prior authorization depending on the member's benefit plan. Verify authorization requirements against the member contract and the plan's prior authorization list.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedure code billing statuses and prior authorization guidance (code list)

Policy CodePolicy N/A

Change TypeAdditions / reclassifications (MP Criteria, EIU, Non Covered) and date updates

Effective DateVaries by code (see code-level entries)

Next Review DateN/A

Key ActionFor codes labeled 'MP Criteria' or 'Unlisted', submit for Recommended Clinical Review to avoid post-service review and obtain prior authorization where required by the member's contract.

On This Page

Code status mapping (per-code entries)

Per-code status mapping and sample per-code coverage leaves. Each code below is mapped to one or more operational labels (MP Criteria, Non Covered, EIU, Unlisted, Prior Authorization may be required) and includes any explicit date notes present in the source.

00797 — MP Criteria; submit for Recommended Clinical Review to avoid post-service review.