CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Cosmetic and Reconstructive Procedures (CPT code list excerpt)

This document lists CPT procedure codes and administrative notes used by Blue Cross Blue Shield - New Mexico for cosmetic and reconstructive procedures and related services; it affects providers submitting claims and prior authorization/medical record requests.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCosmetic and Reconstructive Procedures (CPT code list excerpt)

Policy CodePolicy N/A

Change TypeNo material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required medical records (pre-op evaluation, history & physical with functional impairment, and operative report) and obtain AIM prior authorization where indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+CPT codes listed in this partial extract

AIM referencedAIM prior auth referenced

Some removedCodes removed effective 1/1/2023

Green highlightAIM-managed subset

2022-09-22Document last updated

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Coverage Criteria and Notes

Documentation-based coverage note

Codes listed with required documentation and cross-referenced BCBSNM medical policies.

Documentation required for listed CPT codes: Pre-operative evaluation, history and physical including functional impairment, and operative report (some codes require photographs).

See individual code entry and referenced BCBSNM medical policies (e.g., SUR716.xxx series).

Transplant documentation requirements

Documentation-based coverage conditions noted for transplant-related CPTs.

Transplant documentation: If transplant approval is on record: submit date of transplant. If no transplant approval: submit history and physical, transplant evaluation, and date of transplant.

Applies to many transplant-related CPTs; may also require operative/procedure reports and documentation of medical necessity.

The presence of CPT codes on this administrative listing does not guarantee coverage under a member's benefits contract. Member benefits vary; providers should consult the member benefit booklet or contact customer service to confirm whether a specific procedure or supply is covered. Green-highlighted codes in the source are managed by AIM and may have additional authorization requirements.

Several breast surgery CPT codes in the list include administrative annotations that they were removed effective 1/1/2023. Examples shown in the source include 19330, 19340, and 19342; providers should not rely on code presence here as indicating valid billing after the noted removal date.

Some unlisted procedure CPT entries include explicit add/remove history in the administrative notes. For example, 43499 (Unlisted procedure, esophagus) is shown as Added 4/1/2021 and Removed 4/1/2022. These date annotations are administrative and indicate when the entry was present in the listing, not clinical coverage determinations.

The source notes that several female genital procedure CPT entries require documentation and that at least one code in this group was removed: 56810 (repair of perineum) is indicated in the excerpt as removed effective 1/1/2023. For remaining codes in the group the document lists required supporting records (H&P, documentation of medical necessity, operative report).

This excerpt does not list explicit clinical exclusions for most entries, but it does flag unlisted CPTs for required supporting information. Specifically, 64999 (unlisted nervous system surgery) requires submission of documentation describing the services, including a history and physical and the operative or procedure report.

The excerpted genetic and molecular testing entries do not state explicit coverage or exclusion criteria within this list. Instead, these entries reference AIM Specialty Health for prior authorization and link to AIM clinical guidelines and the AIM provider portal/phone for authorization and clinical guidance.

No additional miscellaneous notes are present in this excerpt beyond the administrative annotations, AIM references, and documentation requirements already summarized in other sections.

CPT / Genetic / Radiology Code Listings

Prior Authorization, Documentation, and Submission Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for many services listed below and managed by AIM Specialty Health. Submit prior authorization requests via the AIM provider portal (https://aimspecialtyhealth.com/providerportal/) or by phone at 1-800-859-5299. Failure to obtain AIM authorization where indicated may result in claim denial.

AIM prior authorization required for numerous CPT codes across specialties (musculoskeletal, radiology, radiation therapy, lab/genetics, transplant, etc.). See code list for specifics (codes flagged with AIM).
When AIM manages a code, authorization is required prior to service and AIM clinical guidelines apply.
AIM-managed codes may be denied without prior authorization; check the AIM portal for per-code requirements and guideline links.

Documentation Required

Submit medical documentation as indicated with authorization requests or for claim review. Required records frequently include a recent history and physical, pre-operative evaluation, operative/procedure report, and documentation of medical necessity or plan of care.

Policy Background and Scope

This partial extract is an administrative CPT code listing associated with Blue Cross Blue Shield of New Mexico medical policies (for example, SUR716.xxx series). It is intended as an index of CPT entries and administrative notes (dates, AIM management flags, and documentation prompts) rather than a standalone clinical coverage policy. Providers should follow the referenced BCBSNM medical policies and authorization instructions for clinical coverage decisions.

Key Terms and Definitions

CPT entry format (descriptor + 'Medical Records Request' examples)

CPT descriptorShort descriptor (example: 'CORRECT SKIN COLOR', 'INSERT TISSUE EXPANDER(S)', 'DERMABRASION')

Medical Records Request fieldAssociated 'Medical Records Request information required' (example: 'Pre‑operative evaluation, history and physical including functional impairment, and operative report')

Category/Clinical Policy linkageEntries include Category (e.g., Outpatient Medical and surgical services) and Medical Policy Number (e.g., SUR716.001)

Pre-operative documentation definition

DefinitionPre‑operative documentation = pre‑operative evaluation, history and physical (including functional impairment) and operative report

Use cases

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCosmetic and Reconstructive Procedures (CPT code list excerpt)

Policy CodePolicy N/A

Change TypeNo material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required medical records (pre-op evaluation, history & physical with functional impairment, and operative report) and obtain AIM prior authorization where indicated.

SourceLink

On This Page

History and physical and documentation of medical necessity are commonly required for gender-related and reconstructive procedures (examples: codes in SUR717.* and SUR716.*).
For eyelid repair codes (e.g., 67901, 67902) include a letter of medical necessity describing the condition treated.
Unlisted procedure codes (e.g., 41899, 43499, 43999, 47999, 64999) require submission of documentation describing the services — include history/physical and operative or procedure reports.
Pre-operative documentation requirements are noted for nasal reconstruction codes (e.g., 30400, 30410) and must include functional impairment where indicated.

Documentation Required

Transplant Approval and Documentation

Transplant procedures have special authorization and documentation rules. If transplant approval is already on record, provide the date of transplant. If no prior transplant approval exists, submit the transplant evaluation, history and physical, and date of transplant.

Many transplant CPTs (heart, lung, liver, pancreas, small bowel, hematopoietic cell transplants, etc.) require documentation of transplant approval or full transplant evaluation and related operative/procedure reports.
Submit supporting documentation to describe services for unlisted transplant-related CPTs (e.g., 37799) including history/physical and operative/procedure report.
Transplant and device documentation requirements may include device-specific letters of medical necessity (e.g., implantable defibrillator lead/device entries such as 33249).

Note

AIM Portal and Guideline References

AIM applies clinical guideline linkage and per-CPT referral/authorization rules. Follow the AIM portal or phone instructions for submission and consult AIM clinical guidelines for medical necessity criteria.

Where AIM is listed next to a CPT code, use AIM for prior authorization and review the AIM resources/clinical guidelines link.
Clinical area and guideline links are provided in the code list — use these to support medical necessity in the authorization request.
For radiology and PET/CT/MRI codes, confirm AIM prior authorization requirements and relevant imaging guidelines before scheduling (see entries in chunks 162, 163, 180, 214, 216, 223).

Note

Coverage Not Guaranteed — Verify Member Benefits

Coverage is not guaranteed by inclusion on this list. Member benefits and contract-specific coverage vary. Always consult the member benefit booklet or contact customer service to determine coverage for a specific member.

The code list is not exhaustive; codes highlighted as AIM-managed indicate administrative management, not automatic coverage.
Presence of a code on the list does not guarantee coverage under a member's benefits contract.

Note

Code List Changes and Removal Risk

Codes may be added or removed over time. Some CPTs previously listed have been removed or had effective-date changes; check current AIM and payer resources to confirm whether a code still requires authorization.

Examples of removal risk: several codes display 'Removed effective' notes in the code table — verify active status before submission.
Code lists and management vendors change; confirm per-code requirements in AIM and payer documentation.

Prior Authorization

Flagged Codes (examples)

Some codes are specifically flagged for AIM review — for example CPT 58346 and many musculoskeletal, radiology, and genetic testing codes. When a code is flagged with AIM in the code list, submit authorization to AIM with required documentation.

CPT 58346 is AIM-managed and added 4/1/2021 — authorization required.
Many musculoskeletal and spine codes (e.g., 22224, 22226, 22510, 63043, 63044, 63685, 64451 series) are AIM-managed.
Genetic and laboratory CPTs (e.g., 81182–81188, 81200–81210, 81253–81255, 81320–81322) indicate AIM review for prior authorization.

Prior Authorization

Provider Submission Checklist and Contact

Operational notes for providers: include the specific documentation requested on the code-level rows when submitting to AIM or for claims review. Examples below consolidate frequent submission items — do not duplicate items already present in per-code guidance.

Authorization contact: AIM provider portal (https://aimspecialtyhealth.com/providerportal/) or phone 1-800-859-5299.
Include: recent history & physical, pre-operative evaluation (when listed), operative or procedure report, plan of care, and documentation of prior conservative therapy or functional impairment where applicable.
Eyelid repair and related ophthalmic codes: include a letter of medical necessity for functional indications.
Unlisted CPT codes (e.g., 64999) — submit full description and supporting documentation; AIM may require additional materials.
For nasal reconstruction (30400/30410), ensure pre-operative documentation includes functional impairment and operative report.

Note

Follow AIM and Payer Instructions

Follow AIM portal and phone instructions and reference AIM clinical guidelines for any additional criteria. Contact AIM for any uncertainty about per-code requirements; also contact BCBSNM customer service for member-specific coverage questions.

Where AIM is the listed manager, use AIM’s portal/phone for prior authorization and to access guideline documents.
If AIM requires additional documentation, supply it in a timely manner to avoid delays or denials.
BCBSNM member coverage questions: consult the member benefit booklet or customer service to confirm benefit-level coverage.

Required for many listed procedures including contour defect corrections and tissue expander placement (see individual code entries)

Additional items sometimes requestedFor some eyelid codes, photographs of affected eyes are also requested

AIM definition and portal/phone reference

AIM (utilization management vendor)AIM Specialty Health — provider portal https://aimspecialtyhealth.com/providerportal/ or phone 1‑800‑859‑5299

Function in documentReferenced as prior authorization/contact path and source for clinical guidelines for many CPT codes

Documentation linkageEntries commonly include AIM clinical guidelines URL alongside AIM portal/phone information

Hematopoietic Cell Transplantation (HCT) referenced

HCT termHematopoietic Cell Transplantation (HCT) — referenced with transplant code group (e.g., 38232) and associated donor/recipient information

Documentation requirementIf transplant approval on record: submit date of transplant; if not: submit history & physical, transplant evaluation, and date of transplant

Clinical contextAssociated with treatment for conditions such as acute myelogenous leukemia (AML) in code entries

AIM (repeat) — utilization management vendor

AIM (vendor) repeat definitionAIM Specialty Health — utilization management vendor for prior authorization via portal or phone (1‑800‑859‑5299); AIM clinical guidelines apply

Document usageAIM references accompany lab, imaging and procedure codes to indicate authorization/review pathways

Guideline linkEntries include AIM clinical guidelines URL for review criteria

BRCA1/BRCA2 codes definition example

BRCA1/BRCA2 code examples81212 = BRCA1 & BRCA2 variant analysis; 81215 = BRCA1 known familial variant; 81217 = BRCA2 full sequence / known familial variant

Authorization/GUIDELINESBRCA entries reference AIM portal/phone and AIM clinical guidelines in the document

Service typeListed under Lab/Genetic testing entries with 'Added' dates (e.g., Added 1/1/2021)

GJB2/GJB6 codes definition example

GJB2/GJB6 code examples81253 = GJB2 gene full sequence / known familial variants; 81254 = GJB6 gene analysis common variants

Authorization/GUIDELINESEntries reference AIM portal/phone and AIM clinical guidelines for these genetic tests

Added dateBoth codes show 'Added 1/1/2021' in entries