Blue Cross Blue Shield NM — Non‑Covered Lab Codes Policy Update

Coverage Criteria and Code Notes

Code definitions — informational

code_definitions: This section provides HCPCS/G-code definitions and required components/times for remote in‑home visits and oncology demonstration project descriptors; the entries are informational code definitions and do not state payer‑specific medical necessity criteria.

The codes listed in this document are designated as not covered by the Plan for claims submission. These entries comprise the Plan's Non‑Covered Code List (effective on or before January 1, 2026) and are not subject to pre‑service review; providers should not expect coverage or payment for services billed with codes appearing on this list.

The HCPCS code A9270 is listed in the file with the description “Non‑covered item or service.” This label indicates that A9270 is included on the Plan’s Non‑Covered Code List and is not eligible for coverage under this policy.

Portions of the document that provide HCPCS/G‑code definitions (for example, Medicare demonstration project descriptors) are informational code descriptions and do not, by themselves, state additional payer‑level coverage exclusions beyond placement on the Non‑Covered Code List. In other words, those chunks contain code definitions but do not include explicit, separate exclusion policy language.

The BPCI Advanced code G9987 is described as a model home visit performed by clinical staff for a non‑homebound individual. The listing explicitly states that G9987 “may not be billed during a period covered by a transitional care management code.” Providers must avoid billing G9987 for any 30‑day period already billed under a transitional care management service.

The code definition sections in these chunks provide descriptive and timing requirements for several HCPCS/G codes but do not contain explicit statements using the phrase “not medically necessary” for the codes defined there. Coverage status is determined by the presence of a code on the Non‑Covered Code List rather than additional 'not medically necessary' text in these chunks.

The document includes HCPCS code S9986 with the description “Not medically necessary service (patient is aware that service not medically necessary).” Its inclusion on the list signals that this code is identified as a non‑medically necessary service; however, presence on the list does not by itself establish coverage under any member benefit contract and claims should be adjudicated per the member’s plan terms.

Laboratory and molecular diagnostic codes — listed as non‑covered

The following laboratory and molecular procedure codes are listed on the Plan's Non‑Covered Code List and are not covered by the Plan.

not_covered_examples: Specific laboratory/molecular procedure codes explicitly listed as not covered include (examples): 0084U (red blood cell antigen genotyping), 0086U (infectious disease organism identification by rRNA FISH), 0091U, 0092U, 0093U, 0095U, 0096U, 0105U, 0107U, 0108U, 0112U, 0115U, 0116U, 0117U, 0119U, 0121U, 0122U, 0123U, 0140U, 0141U, 0142U, and 0152U. No covered indications are provided in this document for these laboratory/molecular codes.

Providers should reference the searchable PDF Non‑Covered Code List to confirm presence of a specific code and its effective/ending dates.

Non-Covered and Listed Codes

Sample non-covered laboratory CPT/HCPCS codesCPTNot Covered

0084U	Red blood cell antigen typing, DNA, genotyping of 10 blood groups with phenotype prediction of 37 red blood cell antigens.
0086U	Infectious disease (bacterial and fungal), organism identification, blood culture, using rRNA FISH, 6 or more organism targets, reported as positive or negative with phenotypic minimum inhibitory concentration (MIC)-based antimicrobial

Additional non-covered lab/diagnostic molecular codesCPTNot Covered

0091U	Oncology (colorectal) screening, cell enumeration of circulating tumor cells, utilizing whole blood, algorithm, for the presence of adenoma or cancer, reported as a positive or negative result.
0092U	Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy.
0093U	Prescription drug monitoring, evaluation of 65 common drugs by LC-MS/MS, urine, each drug reported detected or not detected.
0095U	Eosinophilic esophagitis, 2 protein biomarkers (Eotaxin-3 [CCL26 {C-C motif chemokine ligand 26}] and Major Basic Protein [PRG2 {proteoglycan 2, pro eosinophil major basic protein}]-1), enzyme- linked immunosorbent assays (ELISA), specimen obtained by esophageal string test device, algorithm reported as probability of active or inactive eosinophilic esophagitis.
0096U	Human papillomavirus (HPV), high-risk types (ie, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68), male urine.

Non-covered infectious disease, specialty lab and molecular codesCPTNot Covered

0105U	Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD).
0107U	Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method.
0108U	Gastroenterology (Barrett's esophagus), whole slide digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers and morphology, formalin-fixed paraffin- embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer.
0112U	Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene.
0115U	Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
0116U	Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with LC-MS/MS, oral fluid, algorithm results reported as a patient-compliance measurement with risk of drug to drug interactions for prescribed medications.
0117U	Pain management, analysis of 11 endogenous analytes, LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain.
0119U	Cardiology, ceramides by liquid chromatography-tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events.
0121U	Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood.
0122U	Sickle cell disease, microfluidic flow adhesion (P-Selectin), whole blood.

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Miscellaneous non-covered procedural and vaccine codesmixedNot Covered

86910	Blood typing, for paternity testing, per individual; ABO, Rh and MN.
86911	Blood typing, for paternity testing, per individual; each additional antigen system.
11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions.
11201	Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions.
90584	Dengue vaccine, quadrivalent, live, 2 dose schedule, for subcutaneous use.
90589	Chikungunya virus vaccine, live attenuated, for intramuscular use.
90612	Influenza virus vaccine, trivalent, and SARS-CoV-2 vaccine, mRNA-LNP, 31.7 mcg/0.32 mL dosage, IM.
90613	Influenza virus vaccine, quadrivalent, and SARS-CoV-2 vaccine, mRNA-LNP, 40 mcg/0.4 mL dosage, IM.
90637	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, IM.
90638	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, IM.

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Listed CPT CodesCPT

99450

Life insurance or disability examination including measurement of height, weight, blood pressure, medical history, collection of blood/urinalysis, documentation/certificates

CPT / Remote monitoring and disability exam codesCPT

99451	Interprofessional telephone/Internet/EHR assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time.
99452	Interprofessional telephone/Internet/EHR referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes.
99453	Remote monitoring of physiologic parameter(s); initial set-up and patient education on use of equipment.
99454	Remote monitoring device supply with daily recordings or programmed alerts, 16-30 days in a 30-day period.
99455	Work related or medical disability examination by the treating physician including history, exam, diagnosis, impairment calculation, treatment plan, documentation.
99456	Work related or medical disability examination by other than treating physician including similar elements.
99457	Remote physiologic monitoring treatment management services; clinical staff/physician/OQP time per month requiring 1 real-time interactive communication; first 20 minutes.

A- and D- codes (supplies, durable medical equipment, dental)HCPCS | D (Dental)

A4458	Enema bag with tubing, reusable
A4520	Incontinence garment, any type (e.g., brief, diaper), each
A4553	Non-disposable underpads, all sizes
A4554	Disposable underpads, all sizes
A4890	Contracts, repair and maintenance, for hemodialysis equipment
A4927	Gloves, non-sterile, per 100
A4931	Oral thermometer, reusable, any type, each
A4932	Rectal thermometer, reusable, any type, each
A9150	Non-prescription drugs
A9152	Single vitamin/mineral/trace element, oral, per dose, not otherwise specified

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E-codes (durable medical equipment and accessories)HCPCS

E0210	Electric heat pad, standard
E0217	Water circulating heat pad with pump
E0218	Fluid circulating cold pad with pump, any type
E0236	Pump for water circulating pad
E0240	Bath/shower chair, with or without wheels, any size
E0241	Bath tub wall rail, each
E0242	Bath tub rail, floor base
E0243	Toilet rail, each
E0244	Raised toilet seat
E0245	Tub stool or bench

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G-codes (interprofessional services, primary care management, digital mental health)HCPCS | G-codes

G0276	Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved CED clinical trial
G0293	Noncovered surgical procedure(s) using conscious sedation, regional, general or spinal anesthesia in a Medicare qualifying clinical trial, per day
G0294	Noncovered procedure(s) using either no anesthesia or local anesthesia only, in a Medicare qualifying clinical trial, per day
G0538	Atherosclerotic cardiovascular disease (ASCVD) risk management services; clinical staff time; per calendar month
G0546	Interprofessional telephone/Internet/EHR assessment and management service by practitioner in mental health-limited specialty; 5-10 minutes
G0547	Interprofessional telephone/Internet/EHR assessment and management service by practitioner in mental health-limited specialty; 11-20 minutes
G0548	Interprofessional telephone/Internet/EHR assessment and management service by practitioner in mental health-limited specialty; 21-30 minutes
G0549	Interprofessional telephone/Internet/EHR assessment and management service by practitioner in mental health-limited specialty; 31+ minutes
G0550	Interprofessional telephone/Internet/EHR assessment and management service by practitioner in mental health-limited specialty; written report, 5+ minutes
G0551	Interprofessional telephone/Internet/EHR referral service(s) by treating/requesting practitioner in mental health-limited specialty; 30 minutes

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G-code group (quality measures, oncology demonstration project, BP/BMI/medication measures)HCPCS | G-codes

G8395	Left ventricular ejection fraction (LVEF) >= 40% or documented as normal or mildly depressed
G8396	Left ventricular ejection fraction (LVEF) not performed or documented
G8397	Dilated macular or fundus exam performed including documentation of macular edema presence/absence and retinopathy severity
G8399	Patient with documented results of a central dual-energy X-ray absorptiometry (DXA) ever being performed
G8400	Patient with central DXA results not documented, reason not given
G8404	Lower extremity neurological exam performed and documented
G8405	Lower extremity neurological exam not performed
G8410	Footwear evaluation performed and documented
G8415	Footwear evaluation was not performed
G8416	Clinician documented that patient was not an eligible candidate for footwear evaluation measure

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Oncology practice-guideline and general descriptorsHCPCS

G9053	Oncology; primary focus of visit; expectant management of patient with evidence of cancer for whom no cancer directed therapy is being administered or arranged at present; cancer directed therapy might be considered in the future (for use in a medicare-approved demonstration project).
G9054	Oncology; primary focus of visit; supervising, coordinating or managing care of patient with terminal cancer or for whom other medical illness prevents further cancer treatment; includes symptom management, end-of-life care planning, management of palliative therapies (for use in a medicare-approved demonstration project).
G9055	Oncology; primary focus of visit; other, unspecified service not otherwise listed (for use in a medicare-approved demonstration project).
G9056	Oncology; practice guidelines; management adheres to guidelines (for use in a medicare-approved demonstration project).
G9057	Oncology; practice guidelines; management differs from guidelines as a result of patient enrollment in an institutional review board approved clinical trial (for use in a medicare-approved demonstration project).
G9058	Oncology; practice guidelines; management differs from guidelines because the treating physician disagrees with guideline recommendations (for use in a medicare-approved demonstration project).
G9059	Oncology; practice guidelines; management differs from guidelines because the patient, after being offered treatment consistent with guidelines, has opted for alternative treatment or management, including no treatment (for use in a medicare-approved demonstration project).
G9060	Oncology; practice guidelines; management differs from guidelines for reason(s) associated with patient comorbid illness or performance status not factored into guidelines (for use in a medicare-approved demonstration project).
G9061	Oncology; practice guidelines; patient's condition not addressed by available guidelines (for use in a medicare-approved demonstration project).
G9062	Oncology; practice guidelines; management differs from guidelines for other reason(s) not listed (for use in a medicare-approved demonstration project).

Lung cancer disease-status codesHCPCS

G9063	Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially established as stage i (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9064	Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially established as stage ii (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9065	Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially established as stage iii a (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9066	Oncology; disease status; limited to non-small cell lung cancer; stage iii b- iv at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9067	Oncology; disease status; limited to non-small cell lung cancer; extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9068	Oncology; disease status; limited to small cell and combined small cell/non-small cell; extent of disease initially established as limited with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9069	Oncology; disease status; small cell lung cancer, limited to small cell and combined small cell/non-small cell; extensive stage at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9070	Oncology; disease status; small cell lung cancer, limited to small cell and combined small cell/non-small; extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).

Breast cancer disease-status codesHCPCS

G9071	Oncology; disease status; invasive female breast cancer ... stage i or stage iia-iib; or t3, n1, m0; and er and/or pr positive; with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9072	Oncology; disease status; invasive female breast cancer ... stage i, or stage iia-iib; or t3, n1, m0; and er and pr negative; with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9073	Oncology; disease status; invasive female breast cancer ... stage iiia-iiib; and not t3, n1, m0; and er and/or pr positive; with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9074	Oncology; disease status; invasive female breast cancer ... stage iiia-iiib; and not t3, n1, m0; and er and pr negative; with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9075	Oncology; disease status; invasive female breast cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).

Prostate cancer disease-status codesHCPCS

G9077	Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell type; t1-t2c and gleason 2-7 and psa <= 20 at diagnosis with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9078	Oncology; disease status; prostate cancer ... t2 or t3a gleason 8-10 or psa > 20 at diagnosis with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9079	Oncology; disease status; prostate cancer ... t3b-t4, any n; any t, n1 at diagnosis with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9080	Oncology; disease status; prostate cancer, limited to adenocarcinoma; after initial treatment with rising psa or failure of psa decline (for use in a medicare-approved demonstration project).

Colon cancer disease-status codesHCPCS

G9083	Oncology; disease status; prostate cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9084	Oncology; disease status; colon cancer ... extent of disease initially established as t1-3, n0, m0 with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9085	Oncology; disease status; colon cancer ... extent of disease initially established as t4, n0, m0 with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9086	Oncology; disease status; colon cancer ... extent of disease initially established as t1-4, n1-2, m0 with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9087	Oncology; disease status; colon cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive with current clinical, radiologic, or biochemical evidence of disease (for use in a medicare-approved demonstration project).
G9088	Oncology; disease status; colon cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive without current clinical, radiologic, or biochemical evidence of disease (for use in a medicare-approved demonstration project).
G9089	Oncology; disease status; colon cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).

Rectal and esophageal cancer disease-status codesHCPCS

G9090	Oncology; disease status; rectal cancer ... extent of disease initially established as t1-2, n0, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9091	Oncology; disease status; rectal cancer ... extent of disease initially established as t3, n0, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9092	Oncology; disease status; rectal cancer ... extent of disease initially established as t1-3, n1-2, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence or metastases (for use in a medicare-approved demonstration project).
G9093	Oncology; disease status; rectal cancer ... extent of disease initially established as t4, any n, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9094	Oncology; disease status; rectal cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9095	Oncology; disease status; rectal cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9096	Oncology; disease status; esophageal cancer ... extent of disease initially established as t1-t3, n0-n1 or nx (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9097	Oncology; disease status; esophageal cancer ... extent of disease initially established as t4, any n, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9098	Oncology; disease status; esophageal cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9099	Oncology; disease status; esophageal cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).

Gastric, pancreatic, head & neck disease-status codesHCPCS

G9100	Oncology; disease status; gastric cancer ... post r0 resection (with or without neoadjuvant therapy) with no evidence of disease recurrence, progression, or metastases (for use in a medicare-approved demonstration project).
G9101	Oncology; disease status; gastric cancer ... post r1 or r2 resection (with or without neoadjuvant therapy) with no evidence of disease progression, or metastases (for use in a medicare-approved demonstration project).
G9102	Oncology; disease status; gastric cancer ... clinical or pathologic m0, unresectable with no evidence of disease progression, or metastases (for use in a medicare-approved demonstration project).
G9103	Oncology; disease status; gastric cancer ... clinical or pathologic m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9104	Oncology; disease status; gastric cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9105	Oncology; disease status; pancreatic cancer ... post r0 resection without evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9106	Oncology; disease status; pancreatic cancer ... post r1 or r2 resection with no evidence of disease progression, or metastases (for use in a medicare-approved demonstration project).
G9107	Oncology; disease status; pancreatic cancer ... unresectable at diagnosis, m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9108	Oncology; disease status; pancreatic cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9109	Oncology; disease status; head and neck cancer ... extent of disease initially established as t1-t2 and n0, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).

Head & neck and ovarian disease-status codesHCPCS

G9110	Oncology; disease status; head and neck cancer ... extent of disease initially established as t3-4 and/or n1-3, m0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9111	Oncology; disease status; head and neck cancer ... m1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a medicare-approved demonstration project).
G9112	Oncology; disease status; head and neck cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9113	Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic stage ia-b (grade 1) without evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9114	Oncology; disease status; ovarian cancer ... pathologic stage ia-b (grade 2-3); or stage ic (all grades); or stage ii; without evidence of disease progression, recurrence, or metastases (for use in a medicare-approved demonstration project).
G9115	Oncology; disease status; ovarian cancer ... pathologic stage iii-iv; without evidence of progression, recurrence, or metastases (for use in a medicare-approved demonstration project).

Hematologic and ovarian disease-status codesHCPCS

G9116	Oncology; disease status; ovarian cancer, limited to epithelial cancer; evidence of disease progression, or recurrence, and/or platinum resistance (for use in a medicare-approved demonstration project).
G9117	Oncology; disease status; ovarian cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9123	Oncology; disease status; chronic myelogenous leukemia, limited to philadelphia chromosome positive and/or bcr-abl positive; chronic phase not in hematologic, cytogenetic, or molecular remission (for use in a medicare-approved demonstration project).
G9124	Oncology; disease status; chronic myelogenous leukemia ... accelerated phase not in hematologic cytogenetic, or molecular remission (for use in a medicare-approved demonstration project).
G9125	Oncology; disease status; chronic myelogenous leukemia ... blast phase not in hematologic, cytogenetic, or molecular remission (for use in a medicare-approved demonstration project).
G9126	Oncology; disease status; chronic myelogenous leukemia ... in hematologic, cytogenetic, or molecular remission (for use in a medicare-approved demonstration project).

Multiple myeloma, breast, prostate codesHCPCS

G9128	Oncology; disease status; limited to multiple myeloma, systemic disease; smoldering, stage i (for use in a medicare-approved demonstration project).
G9129	Oncology; disease status; limited to multiple myeloma, systemic disease; stage ii or higher (for use in a medicare-approved demonstration project).
G9130	Oncology; disease status; limited to multiple myeloma, systemic disease; extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9131	Oncology; disease status; invasive female breast cancer ... extent of disease unknown, staging in progress, or not listed (for use in a medicare-approved demonstration project).
G9132	Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-refractory/androgen-independent ... clinical metastases (for use in a medicare-approved demonstration project).
G9133	Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-responsive; clinical metastases or m1 at diagnosis (for use in a medicare-approved demonstration project).

Lymphoma, CML, and demonstration clinic codesHCPCS

G9134	Oncology; disease status; non-hodgkin's lymphoma, any cellular classification; stage i, ii at diagnosis, not relapsed, not refractory (for use in a medicare-approved demonstration project).
G9135	Oncology; disease status; non-hodgkin's lymphoma, any cellular classification; stage iii, iv, not relapsed, not refractory (for use in a medicare-approved demonstration project).
G9136	Oncology; disease status; non-hodgkin's lymphoma, transformed from original cellular diagnosis to a second cellular classification (for use in a medicare-approved demonstration project).
G9137	Oncology; disease status; non-hodgkin's lymphoma, any cellular classification; relapsed/refractory (for use in a medicare-approved demonstration project).
G9138	Oncology; disease status; non-hodgkin's lymphoma, any cellular classification; diagnostic evaluation, stage not determined, evaluation of possible relapse or non-response to therapy, or not listed (for use in a medicare-approved demonstration project).
G9139	Oncology; disease status; chronic myelogenous leukemia ... extent of disease unknown, staging in progress, not listed (for use in a medicare-approved demonstration project).
G9140	Frontier extended stay clinic demonstration; describes stay duration, conditions, and payment periods for frontier extended stay clinics (for use in a CMS demonstration project).

Remote in-home (BPCI Advanced) visit codesHCPCSCovered

G9978	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; requires problem focused history, problem focused exam, and straightforward medical decision making; typically 10 minutes; furnished in real time using interactive audio and video technology.
G9979	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; requires expanded problem focused history, expanded problem focused exam, and straightforward medical decision making; typically 20 minutes; furnished in real time using interactive audio and video technology.
G9980	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; requires detailed history, detailed exam, and medical decision making of low complexity; typically 30 minutes; furnished in real time using interactive audio and video technology.
G9981	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; requires comprehensive history, comprehensive exam, and medical decision making of moderate complexity; typically 45 minutes; furnished in real time using interactive audio and video technology.
G9982	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; requires comprehensive history, comprehensive exam, and medical decision making of high complexity; furnished in real time using interactive audio and video technology.

BPCI Advanced G-series codesHCPCS

G9978	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; typically 10 minutes; requires problem focused history, problem focused exam, and straightforward MDM; furnished in real time using interactive audio and video technology.
G9979	Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved BPCI Advanced model episode of care; typically 20 minutes; expanded problem focused history/exam; straightforward MDM; real-time audio/video.
G9980	Remote in-home visit for the evaluation and management of a new patient for BPCI Advanced; typically 30 minutes; detailed history/exam; low complexity MDM; real-time audio/video.
G9981	Remote in-home visit for the evaluation and management of a new patient for BPCI Advanced; typically 45 minutes; comprehensive history/exam; moderate complexity MDM; real-time audio/video.
G9982	Remote in-home visit for the evaluation and management of a new patient for BPCI Advanced; typically 60 minutes; comprehensive history/exam; high complexity MDM; real-time audio/video.
G9983	Remote in-home visit for evaluation and management of an established patient for BPCI Advanced; typically 10 minutes; at least 2 of: problem focused history, problem focused exam, straightforward MDM; real-time audio/video.
G9984	Remote in-home visit for established patient for BPCI Advanced; typically 15 minutes; expanded problem focused history/exam; low complexity MDM; real-time audio/video.
G9985	Remote in-home visit for established patient for BPCI Advanced; typically 25 minutes; detailed history/exam; moderate complexity MDM; real-time audio/video.
G9986	Remote in-home visit for established patient for BPCI Advanced; typically 40 minutes; comprehensive history/exam; high complexity MDM; real-time audio/video.
G9987	BPCI Advanced model home visit for patient assessment performed by clinical staff for an individual not considered homebound; may include assessments of clinical status, safety, ADLs, medication reconciliation, connections to services; may not be billed during a period covered by transitional care management code.

Selected J-codesHCPCS

J1726	Injection, hydroxyprogesterone caproate, (makena), 10 mg.
J1729	Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg.
J3570	Laetrile, amygdalin, vitamin b17.
J9057	Injection, copanlisib, 1 mg.
J9285	Injection, olaratumab, 10 mg.
J9313	Injection, moxetumomab pasudotox-tdfk, 0.01 mg.

Misc HCPCS/S/T/V/Q codesHCPCS

L3040	Foot, arch support, removable, premolded, longitudinal, each.
L3050	Foot, arch support, removable, premolded, metatarsal, each.
L3060	Foot, arch support, removable, premolded, longitudinal/metatarsal, each.
M0075	Cellular therapy.
P9099	Blood component or product not otherwise classified.
Q0510	Pharmacy supply fee for initial immunosuppressive drug(s), first month following transplant.
Q0511	Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for the first prescription in a 30-day period.
Q0512	Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for a subsequent prescription in a 30-day period.
Q0521	Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription.
Q2049	Injection, Doxorubicin Hydrochloride, Liposomal, Imported Lipodox, 10 mg.

1–10 of 88

1/9

Effective Date Threshold

Effective date thresholdCodes are effective on or before January 1, 2026 (Fully Insured list effective 1/1/2026; file updated May 2026)

ScopeApplies to procedures/services listed on the Non‑Covered Code List for the Plan

Provider Actions, Prior Auth, and Billing Guidance

Note

Pre-service review requirement

Procedures/services listed on the Non-Covered Code List are not covered by the Plan and are not subject to pre-service review. Providers should confirm that a code appears on the searchable PDF before billing; use Ctrl+F to search by procedure code or description.

These codes are effective on or before 1/1/2026 unless otherwise noted.
Claims submitted with codes on the Non-Covered Code List will be denied as not covered.

Note

CED trial-linked code

G0276 is identified as a procedure performed only in an approved Coverage with Evidence Development (CED) clinical trial (per the listing). When a code is CED-linked, verify trial enrollment and documentation requirements before performing the service.

G0276 — Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved CED clinical trial.

Background

This file is a consolidated Non‑Covered Code List across multiple service categories including laboratory and pathology codes. It explicitly lists numerous laboratory/molecular and specialty lab procedure codes (for example, 0084U, 0086U, 0091U, 0105U, 0112U, 0152U among others) as not covered. The list provides code descriptions and effective/ending dates to support billing and claims validation; providers should use the searchable PDF (Ctrl+F) to confirm whether a specific laboratory code is included on the non‑covered list.

Definitions and Key Terms

Non-covered Code List — definition

DefinitionA Non‑Covered Code List is a list of procedure/service codes that the Plan will not cover for claims submission.

Claim handlingCodes on this list are not subject to pre‑service review and are excluded from coverage unless otherwise noted

Provider actionUse the searchable PDF to confirm whether a code is listed before submitting claims

Remote physiologic monitoring / chronic care management codes

Codes includedRemote physiologic monitoring and chronic care management codes listed: 99453–99457 and 99491

99453Initial set‑up and patient education for remote monitoring of physiologic parameters (effective 1/1/2019)

Ordering and Provider Requirements

Note

No ordering or provider‑type requirements specified

This section contains no ordering‑provider or provider‑type requirements; the file is intended as a searchable non‑covered code list for providers to check codes and dates.

The document notes it is a searchable PDF listing non‑covered procedures/services and does not specify ordering requirements in this section.

Explicitly Not Covered Codes

Specific laboratory and molecular procedure codes are explicitly identified as not covered in the document. Examples include novel or specialized molecular and infectious disease assays such as 0084U, 0086U, 0091U, 0105U, 0112U, 0152U and multiple additional U‑codes and panels; these codes are listed with descriptions and effective/ending dates to guide claims submission and adjudication. Providers must not bill the Plan for services reported with these listed laboratory/molecular procedure codes.

OpenPayer

Non‑Covered Procedure and Service Code List — Laboratory/Pathology (Fully Insured)

Coverage Criteria and Code Notes

Non-Covered and Listed Codes

Provider Actions, Prior Auth, and Billing Guidance

Background

Definitions and Key Terms

Ordering and Provider Requirements

Explicitly Not Covered Codes