The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact customer service to determine coverage for a specific medical service or supply. Green highlighted codes are managed by Carelon (formerly AIM).
COVERAGE CRITERIA — No explicit top-level coverage criteria are present in this excerpt. The list maps procedure and supply codes to BCBSNM medical policies, New Mexico Administrative Code/MCG references, and indicates documentation required for claims. Use referenced SUR and DME policies for detailed medical necessity determinations and exclusions.
Documentation requirements (general): Many entries require submission of history and physical, documentation of medical necessity, operative or procedure report, and plan of care when applicable. For durable medical equipment and wheelchairs, include diagnosis, functional abilities/limitations, duration of condition, and anticipated length of use.
Transplant-related codes (examples): Codes such as 32851, 32852, 37799, 38205, 38242 and others are linked to transplant policies (e.g., SUR703 series). For these codes, submit transplant approval on record (date of transplant) or, if approval is not on file, include history and physical, transplant evaluation, and date of transplant.
Surgical/reconstructive codes (examples): Nasal and sinus surgery and gender assignment/reassignment procedure codes (e.g., 30430–30462, 30520) reference SUR717.001, SUR706.001 and related SUR policies — follow those policies for medical necessity and exclusion determinations.
Durable medical equipment (DME) and wheelchairs: E-codes and K-codes (e.g., E0303, E0465, E1161, E1310, E1399, E2300, E2310, K0011, K0013, K0014, K0800–K0813) reference DME policies (DME101 series) and require history and physical or letter of medical necessity describing diagnosis, functional status, and anticipated length of use. Note: E1310 (nonportable whirlpool, built-in) is listed as Not a covered benefit.
Speech generating devices and accessories: Codes such as E2504, E2510 map to Speech Generating Device policy DME104.009 and require a Letter of Medical Necessity describing functional status and length of need.
Radiology and PET imaging: Several radiology/PET codes (e.g., 70336, 70450, G0219, G0235, G0299, G0300) are managed by Carelon and require authorization via Carelon processes. Failure to obtain required authorization may result in denial.
Drug and infusion codes: J- and C-codes listed map to specialty drug policies and often require recent history and physical, plan of care, and documentation of medical necessity; some codes note replacements of prior C-codes and effective dates.
Home health and therapy service codes: G-codes for home health therapy (e.g., G0151, G0152, G0161) require history and physical, chart notes, and treatment plan with Letter of Medical Necessity and reference NMAC 8.325.9 Home Health Services.
Coding note: The list includes mapping to BCBSNM Medical Policy pages and MCG/NMAC references. Presence on this list indicates cross-reference to policy and documentation expectations but is not a standalone coverage determination.