CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2023 Commercial Outpatient Benefit Recommended Clinical Review for Individual & Family Markets and Fully Insured Group Members Medical Surgical Procedure Code List

A code-level listing mapping CPT/HCPCS procedure codes to routing: Medical Policy Criteria (Recommended Clinical Review), Non Covered, Experimental/Investigational/Unproven (EIU), or Unlisted/Undefined; includes administrative changes (PA removals, adds, retires, and move-to-Recommended-Clinical-Review dates).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 Commercial Outpatient Benefit Recommended Clinical Review for Individual & Family Markets and Fully Insured Group Members Medical Surgical Procedure Code List

Policy CodePolicy N/A

Change TypeAdministrative code-list updates (PA removals; move to Recommended Clinical Review; EIU/non-covered designations; adds/retirements)

Effective Date

Next Review Date

Key ActionFor codes listed as 'MP Criteria', submit for a Recommended Clinical Review (predetermination) to avoid post-service review by BCBS via the Utilization Management website or Availity.

POLICY UPDATE CHANGES

Multiple CPT/HCPCS codes moved from Prior Authorization to Recommended Clinical Review (notably effective 09/18/2023 and 01/01/2024 for many codes); some codes had PA removed effective 09/18/2023; various add/retire dates applied across 2023–2024.

Prior Authorization removed effective 09/18/2023 for a set of stem cell / bone marrow and related CPT codes (examples: 38204, 38205, 38206, 38208-38215, 38232, 38240-38243, 38589).

Several codes were added or marked as EIU / Non Reimbursed (examples: 43290, 43291 added 01/01/2023 as EIU; multiple supply and Q-codes transitioned to EIU / not reimbursed).

Reflects administrative changes in review pathway and coding lists; this part shows routing and status updates (MP Criteria, EIU, Non Covered, Unlisted) rather than new clinical coverage criteria.

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