CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Pred Post Serv Noncovered Code List Aso

A Blue Cross Blue Shield New Mexico Administrative Services Only (ASO) searchable list of CPT/HCPCS procedure codes that are candidates for optional Recommended Clinical Review (predetermination) and are subject to utilization management review; includes effective and ending date ranges for each code entry in this part of the multi-part list.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPred Post Serv Noncovered Code List Aso

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit procedures/services listed for Recommended Clinical Review (Predetermination) to avoid post-service medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

~300Codes listed in this part

2026-01-01ASO list effective date

May 2026Last update

Part 2Document partition

Policy summary & scope

Recommended Clinical Review (Predetermination) — required provider actions

Prior Authorization

Recommended Clinical Review (Predetermination) Submission

Submit requests for Recommended Clinical Review (Predetermination) when the service is a candidate for optional review under Medical Policy criteria. Predetermination helps avoid post-service denials by allowing clinical review of medical necessity and code applicability (effective/ending dates, code descriptors, HCPCS/CPT/J-code mappings). Verify eligibility, benefits and any portal/vendor-specific prior authorization requirements before scheduling.

Submit via Availity or the plan-specified vendor portal (verify portal requirements).
Include clinical documentation that supports medical necessity and demonstrates how the request meets Medical Policy criteria.
Provide exact codes and relevant effective/ending dates in the submission.

Billing Rule

Code and Date Use Requirements

Code reporting and billing must follow the policy's effective and ending date guidance. Use the specified CPT/HCPCS/HCPCS J-codes and modifiers exactly as listed for the date of service; the code effective and end dates govern whether a code is applicable for predetermination, billing, or denial. Ensure code descriptors used on claims match the code listed for that date range.

Use listed CPT/HCPCS codes with their provided Effective Date and Ending Date ranges.
Code effective and end dates determine applicability — some codes may appear multiple times when date ranges overlap within a quarter.
HCPCS and drug-specific J-code mappings must be used according to their mapped effective/expiration dates.

Billing Rule

HCPCS / J-code Mapping and Date Changes

When mapping drug-specific J-codes or applying HCPCS codes, follow the policy's mapping notes and date changes. Maintain documentation of mappings and any clinical rationale used for selecting a specific code or J-code mapping for potential medical policy review.

Map drug-specific J-code mappings and date changes as listed in the policy.
Use HCPCS codes only within their effective date ranges shown in the file.
Retain mapping documentation to support medical policy review.

Documentation Required

Documentation Retention for Medical Policy Review

Retain all documentation that supports medical necessity and the use of listed codes for at least the period required for medical policy review and audit. Documentation should be available for predetermination submissions and post-service review if requested.

Keep clinical records, imaging, operative reports, and any prior authorization correspondence.
Documentation must support Medical Policy Criteria review when submitting for Recommended Clinical Review.

Prior Authorization

Prior authorization may be required

Prior authorization may be required for some services on this list. Confirm whether a prior authorization is needed for the member and service through Availity or the designated vendor portal before providing the service.

Prior authorization requirements vary by product and member — verify via Availity or plan/vendor portal.
Submitting a predetermination does not guarantee coverage; it facilitates medical necessity review prior to service.

Denial Risk

Do not bill covered services with listed noncovered codes

Do not bill covered services using codes that are listed as noncovered in this policy. Billing with noncovered codes may result in claim denials or recoupment. Verify coverage status and replace noncovered codes with the correct covered service codes when appropriate.

Do not bill covered services with listed noncovered codes.
If a code is listed as noncovered for the date of service (per effective/ending dates), do not submit it as a covered procedure.

Presence on this list = candidate for optional review; it does not imply automatic coverage.

Check eligibility/benefits and prior authorization requirements via Availity or the plan/vendor portal before providing services.

Retain documentation supporting medical necessity and the code/date mapping used when submitting predetermination requests.

Code lists included in this part

Noncovered / Recommended noncoverage codes (with effective noncoverage date ranges)CPTNot Covered

0825T	Device evaluation (eg, interrogation or programming), when performed. (Noncoverage effective range entries present in list)
0826T	Programming device evaluation (in person) with iterative adjustment of the implantable device... leadless pacemaker system in single-cardiac chamber. (Noncoverage effective range entries present)
0827T	Digitization of glass microscope slides for cytopathology, fluids, washings, or brushings, except cervical or vaginal; smears with interpretation. (Noncoverage effective range entries present)
A0426	Ambulance service, ALS non-emergency transport, level 1; historical/noncoverage date entries present
A0430	Ambulance service, fixed wing air transport, one way; historical/noncoverage date entries present
A0431	Ambulance service, rotary wing air transport, one way; historical/noncoverage date entries present
A0435	Fixed wing air mileage, per statute mile; historical date entries present
A0436	Rotary wing air mileage, per statute mile; historical date entries present
A0888	Noncovered ambulance mileage, per mile (e.g., beyond closest appropriate facility); historical date entries present
A0999	Unlisted ambulance service; historical date entries present

E-codes (Durable Medical Equipment, devices, accessories)HCPCSNot Covered

E0669	Pneumatic compressor segmental gradient pressure appliance (unspecified variant)
E0670	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
E0671	Segmental gradient pressure pneumatic appliance, full leg
E0672	Segmental gradient pressure pneumatic appliance, full arm
E0673	Segmental gradient pressure pneumatic appliance, half leg
E0675	Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency
E0676	Intermittent limb compression device (includes all accessories), not otherwise specified
E0677	Non-pneumatic sequential compression garment, trunk
E0678	Non-pneumatic sequential compression garment, full leg
E0679	Non-pneumatic sequential compression garment, half leg

1–10 of 15

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G-codes (procedures/services)HCPCSNot Covered

G0176	Activity therapy (music/dance/art/play) related to treatment of disabling mental health problems, per session (45+ minutes)
G0235	Pet imaging, any site, not otherwise specified
G0281	Electrical stimulation (unattended) for chronic stage III/IV pressure ulcers and specified ulcers not demonstrating measurable signs of healing after 30 days of conventional care
G0282	Electrical stimulation (unattended) for wound care other than described in G0281
G0329	Electromagnetic therapy for chronic stage III/IV pressure ulcers and specified ulcers not demonstrating healing after 30 days
G0341	Percutaneous islet cell transplant, includes portal vein catheterization and infusion
G0460	Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, per treatment

J-codes (Drugs / biologicals / injections)HCPCSNot Covered

J0013	Esketamine, nasal spray, 1 mg
J0174	Lecanemab-irmb, IV, 1 mg
J0179	Brolucizumab-dbll, 1 mg
J0218	Olipudase alfa-rpcp, 1 mg
J0219	Avalglucosidase alfa-ngpt, 4 mg
J0220	Alglucosidase alfa, 10 mg
J0222	Patisiran, 0.1 mg
J0248	Remdesivir, 1 mg
J0256	Alpha 1 proteinase inhibitor (human), 10 mg
J0485	Belatacept, 1 mg

J-codes (compounded/inhalation/other DME-administered drugs)HCPCSNot Covered

J7660	Isoproterenol hcl, inhalation solution, compounded product, administered through dme, unit dose form, per milligram
J7667	Metaproterenol sulfate, inhalation solution, compounded product, concentrated form, per 10 milligrams
J7670	Metaproterenol sulfate, inhalation solution, compounded product, administered through dme, unit dose form, per 10 milligrams
J7676	Pentamidine isethionate, inhalation solution, compounded product, administered through dme, unit dose form, per 300 milligrams
J7680	Terbutaline sulfate, inhalation solution, compounded product, administered through dme, concentrated form, per milligram
J7681	Terbutaline sulfate, inhalation solution, compounded product, administered through dme, unit dose form, per milligram
J7683	Triamcinolone, inhalation solution, compounded product, administered through dme, concentrated form, per milligram
J7684	Triamcinolone, inhalation solution, compounded product, administered through dme, unit dose form, per milligram
J7685	Tobramycin, inhalation solution, compounded product, administered through dme, unit dose form, per 300 milligrams

HCPCS/other groupings that have status not_coveredHCPCSNot Covered

C1062	Intravertebral body fracture augmentation with implant (e.g., metal, polymer) - device entries with noncoverage dates present
C1605	Pacemaker, leadless, dual chamber; device entries with noncoverage dates present
A2001	Innovamatrix AC, per sq cm (add-on) - listed with noncoverage/administrative date entries

Do not duplicate the document-level statistics here — the per-code groups in the code tables provide the full details for each code. Use the effective and end dates shown with each individual code entry when determining applicability for review or processing.

OpenPayer

Pred Post Serv Noncovered Code List Aso

Policy summary & scope

Recommended Clinical Review (Predetermination) — required provider actions

Codes & date guidance (reporting rules)

Code lists included in this part

Predetermination / Recommended Clinical Review Criteria

Definitions and key terms

FAQs & common questions

Document revision timeline