Blue Cross Blue Shield NM procedure code coverage

Coverage categories and per-code designations

inv-01: General categorization

Codes on this list fall into one of several categories and coverage depends on category and member benefit:

MP Criteria: Procedures/services reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review by BCBS.

Submit pre-service Recommended Clinical Review when indicated; member benefit may still affect coverage.

EIU: Experimental, Investigational and Unproven (EIU): procedures/services not reimbursed by the Plan and not subject to pre-service review.

Check the Clinical Payment and Coding Policy (CPCP) for EIU details.

Non Covered: Procedures/services explicitly labeled 'Non Covered' are not covered by the Plan and are not subject to pre-service review.

Member contract determines applicability; presence on list does not guarantee coverage.

Unlisted/Undefined: Unlisted or undefined procedure codes may be subject to contract or clinical review; supporting documentation and Recommended Clinical Review are advised.

Submit documentation to avoid post-service review.

inv-02: Coverage categories represented in code list

Coverage stance indicated per code label

EIU - Not reimbursed: Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review.

Examples in the list: 17340, 22526, 22527, 28890, 30468.

MP Criteria - Recommended Clinical Review: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Examples: many breast, facial, GI, vascular and surgical procedure codes in the table.

Non Covered: Codes explicitly labeled 'Non Covered' are not covered by the Plan and not subject to pre-service review.

Examples: select dental and supply codes shown in the list.

Unlisted - May require contract/clinical review:

inv-03: Coverage designations

Coverage designations provided inline with codes; follow these designations for review and reimbursement determination.

MP Criteria / Recommended Clinical Review: Procedures labeled 'MP Criteria' or annotated 'Submit for Recommended Clinical Review to avoid post-service review by BCBS' are subject to clinical review and should be submitted for Recommended Clinical Review prior to service when possible.

Applies across many surgical and procedural codes in the list.

EIU (Excluded/Not reimbursed): Procedures labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; claims for these procedures may be denied.

Examples: 28890, 30468, 36473, 36474, 36836, 36837.

Unlisted procedure handling: Unlisted codes (e.g., 22999, 29999, 33999, etc.) may be subject to contract or clinical review; providers should submit clinical documentation and request Recommended Clinical Review to avoid post‑service review.

Follow MP Criteria process for unlisted procedures.

inv-04: Per-code coverage annotations (partial)

Coverage designations and required actions (per-code annotations in this excerpt):

MP Criteria: When a procedure code is marked 'MP Criteria' the service is reviewed against Medical Policy Criteria; providers should submit for Recommended Clinical Review to avoid post-service review by BCBS.

Applies to many vascular, transplant, GI and surgical codes in this segment.

Unlisted procedure codes are not specifically defined or classified and may require contract/clinical review; documentation should be submitted to support medical necessity determinations.

Examples include many 'UNLISTED' CPT entries across specialties.

EIU: Some procedures are marked 'EIU' meaning they are not reimbursed by the Plan and not subject to pre-service review; check the EIU/CPCP policy for details.

Examples in this excerpt: 41530, 43290, 43291.

Non Covered:

inv-05: General coverage linkage to medical policy criteria

Covered when ALL of the following are met

policy-review-requirement: Procedure/service is reviewed against Medical Policy Criteria or is an unlisted procedure that may be subject to contract/clinical review.

Providers should submit for Recommended Clinical Review where indicated; prior authorization may be required per contract for select codes.

inv-06: Per-code coverage stance

Coverage stance and required actions indicated per code:

EIU (Excluded) codes: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed by the Plan and are not eligible for pre-service review.

Examples in the document: 61630, 62263, 62264, 95905, 95919.

MP Criteria codes: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria; providers should submit for Recommended Clinical Review to avoid post-service review.

Examples across specialties include many procedural and diagnostic CPTs in the list.

Unlisted codes are not specifically defined or classified and may be subject to contract/clinical review; submit supporting documentation and request Recommended Clinical Review when indicated.

Many 'UNLISTED' CPT/HCPCS codes are present in the table.

inv-07: Coverage label groups

Coverage status is given per code using the following labels

EIU (Excluded/Not reimbursed): Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review.

Examples include selected molecular/pathology and laboratory assays annotated as EIU in the list.

Non Covered: Codes explicitly marked 'Non Covered' will not be reimbursed and are not subject to pre-service review.

Examples: certain autopsy, behavioral health and supply codes noted as Non Covered.

MP Criteria (requires Recommended Clinical Review): Codes marked 'MP Criteria' must be submitted for Recommended Clinical Review to avoid post-service review; prior authorization may also be required per contract for some codes.

Examples: selected unlisted molecular pathology and immunology procedure codes.

inv-08: MP Criteria / Recommended Clinical Review

Covered when MP Criteria and Recommended Clinical Review submitted

MP Criteria requirement: Procedures/services listed as 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review by BCBS.

Providers should follow the Recommended Clinical Review submission process (Utilization Management/Availity) and include clinical rationale and supporting records.

inv-09: Coverage annotations present in this segment

MP Criteria entries: For CPT codes annotated 'MP Criteria', the procedures/services are reviewed against Medical Policy Criteria and providers should submit for Recommended Clinical Review to avoid post-service review by BCBS.

Applies per individual CPT entries across the document.

Non Covered entries: CPT codes annotated 'Non Covered' are not covered by the Plan and are not subject to pre-service review.

Examples in the list include selected therapy, supply and vaccine codes.

EIU / Not reimbursed entries: Codes annotated 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; check the EIU/CPCP policy for details.

Examples: certain diagnostic assays and device-related codes.

inv-10: Per-code coverage designation (MP Criteria vs EIU)

per-code designation: Each listed code is assigned either 'MP Criteria' (procedures/services reviewed against Medical Policy Criteria — submit for Recommended Clinical Review) or 'EIU' (procedure/service not reimbursed by the Plan; not subject to pre-service review).

No patient-level clinical criteria are provided in this fragment; refer to the applicable Medical Policy or CPCP for full medical necessity rules.

inv-11: Coverage designations

Coverage designations in this section fall into two main categories:

EIU - Not reimbursed: Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; billing these codes may result in denial.

Examples among temporary/Category III and HCPCS entries include many codes flagged EIU.

MP Criteria - Recommended Clinical Review: Codes labeled 'MP Criteria' require submission for Recommended Clinical Review to reduce the risk of post-service denial and to document medical necessity.

Examples: multiple T-codes and C-/A- codes annotated MP Criteria in this section.

inv-12: Per-code coverage designations

MP Criteria entries: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and providers are instructed to 'Submit for Recommended Clinical Review to avoid post-service review by BCBS.'

Per-code annotations appear throughout the coding tables.

EIU (Not reimbursed): Codes labeled 'EIU' are not reimbursed and not subject to pre-service review; check the EIU policy for guidance.

Several T-codes, HCPCS, and other entries are designated EIU in this segment.

Non-Covered categories: Specific HCPCS A- and supply codes are explicitly marked 'Non Covered' and will not be reimbursed by the Plan.

Examples: A4458, A4520, A4553, A4554, A4890, A9273.

Prior Authorization notes: Some ambulance and device codes note that prior authorization may be required per contract; verify PA status before service when applicable.

Entries labeled Non Covered in this coding list denote procedures or services that are not covered by the Plan and are not subject to pre‑service review. Examples appear throughout the list (for example, codes such as 07957, 11200, 11201) and indicate operationally that claims submitted for these codes will not be paid under member benefits unless a separate contract term applies.

Codes labeled EIU are identified as Experimental, Investigational and Unproven and are described in the document as “Procedure/service not reimbursed by the Plan. Not subject to pre‑service review.” These EIU labels (and other Non Covered entries) are exclusions from coverage and claims for such services are expected to be denied when billed (examples cited include codes like 17340 and many others shown in the list).

The code 28890 (HI ENERGY ESWT PLANTAR FASCIA) is explicitly annotated as EIU: Procedure/service not reimbursed by the Plan, i.e., it is considered experimental/investigational and not payable under Plan benefits and is not subject to pre‑service review.

Selected examples of procedure groups designated EIU or otherwise excluded from reimbursement include endovenous mechanical/chemical vein procedures (36473, 36474) and certain arteriovenous fistula procedures (36836, 36837), which the list marks as EIU and not reimbursed by the Plan. These annotations signal that the insurer will not pay for these services as listed.

The code 29440 (Addition Of Walker To Cast) is shown in the list as Non Covered: Procedure/service not covered by the Plan, indicating it is excluded from coverage and not subject to pre‑service review.

A block of dental and gum procedure CPTs (for example, codes in the 41820–41874 range) are specifically labeled Non Covered in the coding list. When codes for excision, grafting, or repair of gingival tissues are annotated this way, they are excluded from Plan reimbursement and not eligible for pre‑service review.

Numerous procedure codes across specialties are flagged EIU or marked as not reimbursed (examples in the document include sensory testing T‑codes such as 0106T–0110T, physiotherapy‑adjacent codes like 97610, and others). These entries are presented as plan exclusions rather than medical‑necessity denials.

The coding excerpt contains many explicit Non Covered and EIU examples across CPT, HCPCS and temporary codes. These labels indicate exclusion from payment (Non Covered) or that the service is experimental/unproven and not reimbursed (EIU); both are operational exclusions rather than clinical medical‑necessity pathways.

A substantial set of HCPCS entries (A‑codes) in the list are explicitly designated Non Covered (for example, A4458, A4520, A4553, A4554) and will not be reimbursed by the Plan. The document uses these labels to operationally exclude items/supplies from payment.

Operationally, codes in this list are assigned per‑code coverage designations—MP Criteria (requires Recommended Clinical Review), EIU (not reimbursed), Non Covered (not covered by the Plan), or Unlisted (may require contract/clinical review). For codes marked MP Criteria, providers are instructed to submit for Recommended Clinical Review to avoid post‑service review; codes marked EIU or Non Covered are exclusions from reimbursement and are not subject to pre‑service review.

Reminder: entries labeled EIU are defined in the list as “Procedure/service not reimbursed by the Plan. Not subject to pre‑service review.” This designation reflects the Plan’s exclusion policy (see the Clinical Payment and Coding Policy reference in the document) and means claims for these services are likely to be denied if billed.

Examples of CPT/laboratory and pathology codes explicitly labeled Non Covered appear in the list (for instance, multiple blood‑typing/paternity and autopsy codes such as 86910, 86911, 88000–88045). These annotations operationally indicate the services will not be paid by the Plan and are not subject to pre‑service review.

Across clinical domains the document surfaces many Non Covered and EIU examples (for example, therapeutic athletic training codes 97169–97172, procedural supply codes, and selected device/product entries). The presence of these labels in the code list signals exclusion from routine reimbursement.

The HCPCS/temporary code segments include numerous U‑ and T‑ codes that are shown as Non Covered or EIU (examples include various wound‑matrix A‑codes and multiple T‑codes). These entries reinforce that product/device codes and many newer temporary codes may be excluded from payment or marked investigational.

The list defines the EIU label as indicating procedures or services that are Experimental, Investigational and Unproven and therefore not reimbursed by the Plan and not subject to pre‑service review; providers should consult the Clinical Payment and Coding Policy (CPCP) for details.

Many entries annotated EIU are explicitly described in the document as excluded from reimbursement; the coding list repeatedly emphasizes that services marked EIU are not subject to pre‑service review and billing these codes will typically result in denial or nonpayment.

Throughout the coding fragment numerous individual entries explicitly state Non Covered in the description text. These are operational exclusions (not clinical medical‑necessity determinations) and are handled as not payable by the Plan, with no pre‑service review required.

The HCPCS section of the list contains specific codes and descriptors that are annotated with exclusionary labels (for example, several A‑codes such as A0430/A0435 with PA notes and many product A‑codes designated EIU or Non Covered). Follow the per‑code annotation when determining reimbursement handling.

Per the document, each listed code will carry one of the plan’s coverage labels — commonly MP Criteria (requires Recommended Clinical Review) or EIU (not reimbursed). The fragment does not supply patient‑level medical necessity criteria; providers should use the per‑code designation and submit Recommended Clinical Review when indicated.

Important operational note: services labeled EIU are not subject to pre‑service review under the list’s conventions. In contrast, services labeled MP Criteria should be submitted for Recommended Clinical Review (pre‑service when appropriate) to avoid post‑service review by BCBS.

Example: code 41530 (Tongue base volume reduction) is shown as EIU with the explicit statement that it is a Procedure/service not reimbursed by the Plan. This illustrates that EIU labeling is used for diverse procedures across specialties.

Example: code 46707 is annotated EIU in the list and carries the explicit not reimbursed by the Plan designation; such entries are treated as exclusions from coverage.

Example: code 65760 (Revision of cornea) is listed as Non Covered: Procedure/service not covered by the Plan, demonstrating that Non Covered labels are applied across procedural specialties.

The list repeatedly notes that items labeled EIU are excluded from reimbursement and that billing these items is likely to result in denial. This is an operational exclusion separate from medical necessity adjudication — providers should check the CPCP/EIU policy for background but expect non‑payment for EIU‑labeled codes.

Behavioral health‑adjacent codes for hypnotherapy and related services (for example, 90885, 90889, 90899, 90875–90876, 90901) are shown in the excerpt as Non Covered or Unlisted, indicating these services are excluded from Plan payment when billed as listed.

Operational implication: codes annotated EIU or labeled Non Covered in this list are expected to be denied or not reimbursed. The document explicitly flags denial risk for these entries and advises providers to verify coverage before delivering or billing such services.

Claims that include EIU‑coded items are likely to be denied because the list marks those services as not reimbursed by the Plan. The coding list contains no clinical exceptions in the fragments shown; check the Clinical Payment and Coding Policy (CPCP) for any broader EIU definitions or cross‑policy guidance.

The document provides many device/product and temporary code examples labeled EIU (not reimbursed) or Non Covered (not covered). These per‑code annotations are the authoritative operational cue for reimbursement — follow the listed designation for each code when adjudicating claims.

The coding fragment uses a set of standard labels (Non Covered, EIU, Unlisted, and MP Criteria) rather than explicit “Not Medically Necessary” text. When codes are shown as Non Covered or EIU, that reflects exclusion from payment rather than a medical‑necessity determination.

What providers must do (authorization, review, documentation)

Prior Authorization

Authorization and review overview

Prior authorization and Recommended Clinical Review requirements vary by procedure, code group, and member contract. Some services require prior authorization per the member’s contract; others are designated "MP Criteria" and must be submitted for Recommended Clinical Review to avoid post-service medical necessity review or denial. Experimental/Investigational/Unproven (EIU) and Non Covered items are not reimbursed and are not subject to pre-service review — billing these without confirmation will result in denial.

Some codes may require Prior Authorization per contract — check the member benefit or contract for PA requirements before scheduling services.
Codes labeled "MP Criteria" (Medical Policy Criteria) must be submitted for Recommended Clinical Review prior to service to avoid post-service review or denial.
Unlisted/Undefined procedure codes may be subject to contract/clinical review and should be submitted for Recommended Clinical Review with supporting documentation.
EIU (Experimental/Investigational/Unproven) codes and Non Covered codes are not reimbursed by the Plan and are not subject to pre-service review — claims will be denied if billed without coverage.
When a code is noted as "Prior Authorization may be required per contract agreement," confirm PA requirements via the member’s benefits or the insurer’s Utilization Management portal.
Some codes have had PA status changed (for example, certain codes were moved from PA to Recommended Clinical Review or had PA removed effective 9/18/2023 or other dates). Verify the current requirement before submission.

Documentation Required

How to request review and required documentation

Submit requests for Recommended Clinical Review or prior authorization using BCBS/Availity Utilization Management channels. Include clinical rationale and supporting records, operative notes, imaging, pathology, and any documentation required by the applicable medical policy. For codes marked MP Criteria or Unlisted, submit complete documentation pre-service to prevent post-service denials.

How to request review: use the insurer’s Utilization Management website or submit via Availity (https://www.availity.com/).
Required submission/documentation guidance: provide clinical rationale, pertinent records, prior conservative therapy details, imaging, and operative reports as applicable.
Recommended Clinical Review documentation: include medical necessity justification and any information specified in the referenced medical policy.
For MP Criteria and Unlisted codes: submit for Recommended Clinical Review pre-service to avoid post-service review or denial.

Denial Risk

Denial risk and non‑reimbursed services

Denial risk is increased when providers bill for Non Covered or EIU-designated services or when MP Criteria / Unlisted codes are not submitted for Recommended Clinical Review pre-service. Check member benefits and policy status — billing Non Covered or EIU items may result in claim denial and patient liability.

Non-reimbursed (EIU) services: these are not covered by the Plan and are not subject to pre-service review; do not bill as payable without confirmation.
Non Covered procedures/code groups: will not be reimbursed and are not subject to pre-service review — billing these will trigger denial.
EIU (not reimbursed) triggers denial: EIU-designated codes are not reimbursed; confirm coverage before performing the service.
MP Criteria review risk: failure to submit Recommended Clinical Review for MP Criteria codes may lead to post-service medical necessity review and denial.
Unlisted procedure review risk: unlisted or undefined codes lacking supporting documentation are at high risk for contract/clinical review denial.
Non-covered HCPCS entries and U-code examples in the list may be labeled Non Covered or EIU — check the code status and member contract prior to service.

Note

Operational notes and selected code examples

Specific operational notes and examples (not exhaustive): many codes across specialties are marked MP Criteria and require Recommended Clinical Review; some codes may additionally state Prior Authorization may be required per contract. PA status for some codes changed on specified dates — always verify current requirements.

Selected examples where Prior Authorization may be required per contract and/or PA status changed: codes with historical PA removed effective 9/18/2023 (e.g., 15824, 15826, 19316, 19318, 21125, 21127, 21145, 21146, 21147, 21248/21249 entries, 36516, hematopoietic/stem cell harvest codes 38204/38215/38232/38241 and others).
Examples of codes moved from PA to Recommended Clinical Review effective 01/01/2024: certain arthroscopy and graft procedure codes (e.g., 29866, 29914–29916 noted as moved).
Transplantation and related procedure codes may note prior authorization per contract; some had PA removed effective dates listed (e.g., many 50xxx–52xxx series entries).
Ambulance/air transport HCPCS (A0430, A0435, etc.) may require PA per contract; verify current PA status.
MP Criteria — Recommended Clinical Review: numerous CPT/HCPCS/Category III codes listed across the document are designated MP Criteria; submit for Recommended Clinical Review pre-service to avoid post-service review.
Unlisted codes (e.g., 19499, 29999, 30999, 31299, 37799, 45999, etc.) are classified as Unlisted/Undefined and may be subject to contract or clinical review; provide full documentation.
Non Covered/Not reimbursed examples: select CPT and HCPCS entries throughout the list are labeled Non Covered or EIU — these will not be reimbursed.

Key term definitions used in this document

MP Criteria definition

DefinitionMP Criteria: Procedures/services reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review by BCBS.

When to submitSubmit Recommended Clinical Review pre-service when indicated to reduce risk of post-service denial

Relation to PASome MP Criteria codes may also require prior authorization per contract; check member contract and code annotations

EIU definition

DefinitionEIU (Experimental, Investigational and Unproven): Procedures/services not reimbursed by the Plan and not subject to pre-service review.

Operational noteClaims for EIU-coded services are not reimbursed; consult the Clinical Payment and Coding Policy (CPCP) for details

Provider impactDo not expect reimbursement for services labeled EIU unless documented exception per CPCP

Unlisted/Undefined definition

DefinitionUnlisted/Undefined: Procedure/service not specifically defined or classified; may be subject to contract or clinical review.

Required actionProvide supporting documentation and submit for Recommended Clinical Review when billing unlisted codes to avoid post-service review

Denial riskUnlisted codes may trigger contract or clinical review and could be denied if unsupported

MP Criteria short definition

Short definitionMP Criteria: Procedures/services reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

ActionSubmit Recommended Clinical Review when MP Criteria applies

PurposeDesignates services that require medical policy review to determine coverage

EIU short definition

Short definitionEIU: Procedures/services not reimbursed by the Plan and not subject to pre-service review.

CheckRefer to CPCP for EIU policy details

Billing impactBilling EIU-coded services will likely result in denial/nonpayment

Unlisted short definition

Short definitionUnlisted: Procedure/service not specifically defined or classified; may require contract/clinical review.

DocumentationProvide detailed operative reports and justification when submitting unlisted codes

Review pathwaySubmit for Recommended Clinical Review to avoid post-service review

EIU reminder entry

ReminderEIU entries mark procedures not reimbursed by the Plan and are not subject to pre-service review; see CPCP for policy details.

ExampleCode 41530 (Tongue base volume reduction) listed as EIU

Provider noteDo not submit for prior authorization; verify member benefits for coverage exceptions

Unlisted reminder entry

ReminderUnlisted procedure codes may be subject to contract or clinical review and could trigger post-service review if not supported.

ExamplesMultiple unlisted CPTs (e.g., 22999, 29999, 43999) appear in the list

Provider actionSubmit supporting documentation and request Recommended Clinical Review when appropriate

Unlisted procedure note

NoteUnlisted procedure codes are not specifically defined and may require contract/clinical review before reimbursement.

ActionAttach operative reports and rationale when billing unlisted CPTs

RiskClaims for unlisted procedures may be denied without adequate documentation

EIU note (CPCP reference)

NoteEIU entries reference the Clinical Payment and Coding Policy (CPCP) — check CPCP for details on EIU determinations and appeals.

ExampleSeveral audiology and diagnostic codes are labeled EIU; consult CPCP for exceptions

Provider guidanceBillers should verify EIU status before submission; do not expect payment for EIU-labeled services

EIU definition with CPCP reference

Definition with CPCP referenceEIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review — refer to the Clinical Payment and Coding Policy (CPCP) for details.

Operational implicationServices labeled EIU are excluded from reimbursement unless CPCP specifies otherwise

Provider recommendationConfirm EIU status and consult CPCP before scheduling or billing

MP Criteria definition (guidance)

GuidanceMP Criteria indicates procedures are reviewed against Medical Policy Criteria and providers should submit for Recommended Clinical Review to avoid post-service review.

ProcessSubmit clinical rationale and supporting records through Utilization Management or Availity

OutcomeRecommended Clinical Review reduces risk of post-service denial but does not guarantee coverage — member benefit applies

Unlisted definition (operational)

Operational definitionUnlisted: Procedure/service not specifically defined or classified; may be subject to contract/clinical review and requires documentation for adjudication.

ActionProvide detailed procedure description and justification when submitting unlisted codes

Reviewer actionReviewer may route to clinical/contract review to determine coverage

EIU reminder

ReminderEIU entries indicate the service is not reimbursed by the Plan and not subject to pre-service review; billing such services will likely be denied.

ExampleCode 41530 flagged as EIU

RecommendationAvoid performing/billing EIU-labeled services without confirmation of coverage exceptions

MP Criteria tag example

ReminderMP Criteria denotes procedures that should be submitted for Recommended Clinical Review prior to service to avoid post-service review.

Provider actionSubmit documentation through Utilization Management or Availity per instructions in the code list

NotePrior authorization may still be required per contract for some MP Criteria codes

MP Criteria operational definition — submit for Recommended Clinical Review

Operational definitionMP Criteria: Submit for Recommended Clinical Review to avoid post-service review; procedures are reviewed against Medical Policy Criteria.

When applicableUse Recommended Clinical Review pathway for pre-service assessment when code annotated MP Criteria

System notePresence on list does not guarantee coverage — member benefit limits apply

EIU operational definition referencing CPCP

Operational definitionEIU: Procedure/service not reimbursed by the Plan; not subject to pre-service review. See the CPCP for policy and exception details.

Clinical noteEIU designation often reflects insufficient evidence of effectiveness

Provider implicationDo not expect reimbursement for EIU-labeled services absent explicit exception

EIU reminder entry

ReminderEIU entries are not subject to pre-service review; claims may be denied — check CPCP for exceptions.

Example41530 listed as EIU in the code list

AdviceVerify coverage before performing EIU-labeled procedures

MP Criteria tag reminder

ReminderSubmit MP Criteria codes for Recommended Clinical Review to reduce post-service review risk.

ProcessUse Utilization Management or Availity link to request review and include clinical documentation

CaveatRecommended Clinical Review does not substitute for contract-required prior authorization where applicable

MP Criteria short tag

Short tagMP Criteria — submit for Recommended Clinical Review

MeaningReviewed against Medical Policy Criteria

Provider notePre-service submission recommended when indicated

EIU short tag

Short tagEIU — not reimbursed by the Plan

ImplicationNot eligible for pre-service review; claims likely denied

ReferenceSee CPCP for further guidance

00640	ANESTH SPINE MANIPULATION - MP Criteria: Submit for Recommended Clinical Review
00797	ANESTH SURGERY FOR OBESITY - MP Criteria: Submit for Recommended Clinical Review
11920	Correct Skin Color 6.0 Cm/< - MP Criteria: Submit for Recommended Clinical Review
11921	Correct Skn Color 6.1-20.0Cm - MP Criteria: Submit for Recommended Clinical Review
07957	Weight Loss - Non Covered
11200	REMOVAL OF SKIN TAGS <W/15 - Non Covered
11201	REMOVE SKIN TAGS ADD-ON - Non Covered

11950	TX CONTOUR DEFECTS 1 CC/< - MP Criteria: Submit for Recommended Clinical Review
11951	TX CONTOUR DEFECTS 1.1-5.0CC - MP Criteria: Submit for Recommended Clinical Review
11952	TX CONTOUR DEFECTS 5.1-10CC - MP Criteria: Submit for Recommended Clinical Review
11954	TX CONTOUR DEFECTS >10.0 CC - MP Criteria: Submit for Recommended Clinical Review
11960	INSERT TISSUE EXPANDER(S) - MP Criteria: Submit for Recommended Clinical Review
11970	RPLCMT TISS XPNDR PERM IMPLT - MP Criteria: Submit for Recommended Clinical Review
11980	IMPLANT HORMONE PELLET(S) - MP Criteria: Submit for Recommended Clinical Review
15271	Skin Sub Graft Trnk/Arm/Leg - MP Criteria; Add effective 04/01/2023
15273	Skin Sub Graft T/A/L Add-On (child) - MP Criteria; Add effective 04/01/2023
15274	Skn Sub Grft T/A/L Child Add - MP Criteria; Add effective 04/01/2023

15758	FREE FASCIAL FLAP MICROVASC - MP Criteria
15769	GRFG AUTOL SOFT TISS DIR EXC - MP Criteria
15771	GRFG AUTOL FAT LIPO 50 CC/< - MP Criteria
15772	GRFG AUTOL FAT LIPO EA ADDL - MP Criteria
15775	HAIR TRNSPL 1-15 PUNCH GRFTS - MP Criteria
15776	HAIR TRNSPL >15 PUNCH GRAFTS - MP Criteria
15780	DERMABRASION TOTAL FACE - MP Criteria
15781	DERMABRASION SEGMENTAL FACE - MP Criteria
15782	DERMABRASION OTHER THAN FACE - MP Criteria
15783	DERMABRASION SUPRFL ANY SITE - MP Criteria

15820	REVISION OF LOWER EYELID - MP Criteria
15821	REVISION OF LOWER EYELID (variant) - MP Criteria
15822	REVISION OF UPPER EYELID - MP Criteria
15823	REVISION OF UPPER EYELID (variant) - MP Criteria
15825	REMOVAL OF NECK WRINKLES - MP Criteria
15828	REMOVAL OF FACE WRINKLES - MP Criteria
15829	REMOVAL OF SKIN WRINKLES - MP Criteria
15830	EXC SKIN ABD - MP Criteria
15832	EXCISE EXCESSIVE SKIN THIGH - MP Criteria
15833	EXCISE EXCESSIVE SKIN LEG - MP Criteria

15876	SUCTION LIPECTOMY HEAD & NECK - MP Criteria
15877	SUCTION LIPECTOMY TRUNK - MP Criteria
15878	SUCTION LIPECTOMY UPPER EXTREM - MP Criteria
15879	SUCTION LIPECTOMY LOWER EXTREM - MP Criteria
15999	UNLISTED PX EXC PRESSURE ULC - Unlisted/subject to review
17106	DESTRUCTION OF SKIN LESIONS - MP Criteria
17107	DESTRUCTION OF SKIN LESIONS (variant) - MP Criteria
17108	DESTRUCTION OF SKIN LESIONS (variant) - MP Criteria
17340	CRYOTHERAPY OF SKIN - EIU: Not reimbursed

OpenPayer

2023 Commercial Outpatient Benefit Recommended Clinical Review — Medical/Surgical Procedure Code List

Coverage categories and per-code designations

Grouped code tables and notable code lists

What providers must do (authorization, review, documentation)

Key term definitions used in this document

17999	UNLISTD PX SKN MUC MEMB SUBQ - Unlisted
17999	(duplicate entry placeholder) - Unlisted

17360	SKIN PEEL THERAPY - MP Criteria
17380	HAIR REMOVAL BY ELECTROLYSIS - MP Criteria
19300	REMOVAL OF BREAST TISSUE - MP Criteria (breast procedural group)