CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2023 New Mexico Medicaid Procedure Codes Requiring Prior Authorization

Part 1 of a multi-part BCBSNM New Mexico Medicaid list mapping CPT/HCPCS codes to prior authorization requirements, required documentation, AIM routing, clinical policy references, and add/remove effective dates. Presence on the list does not guarantee coverage; member benefit contracts vary.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 New Mexico Medicaid Procedure Codes Requiring Prior Authorization

Policy CodePolicy N/A

Change TypeMultiple code additions and removals (per-code)

Effective Date

Next Review Date

Key ActionObtain AIM prior authorization via the AIM provider portal (https://aimspecialtyhealth.com/providerportal/) or phone (1-800-859-5299) and include required H&P, plan of care, operative report or Letter of Medical Necessity as specified per code.

SourceLink

POLICY UPDATE CHANGES

11970 listed as 'Removed effective 1/1/2023'.

15781 and 15782 listed as 'Removed effective 1/1/2023'.

This part lists multiple CPT codes added on various dates (examples: Added 1/1/2021, Added 4/1/2021, Added 10/1/2022) and some codes removed effective 1/1/2023.

Multiple CPT codes (numerous spinal, radiosurgery, AIM-routed codes) added 4/1/2021 and 4/1/2022 as indicated per code entries.

Codes 63194, 63196, 63198 were removed on 4/1/2023.

0056U was removed 4/1/2023; 0208U was removed 4/1/2023; other per-code removed entries are preserved.

AIMPrimary prior auth vendor referenced

manyCodes added 1/1/2021 (common)

severalCodes removed effective 1/1/2023 (noted in part)

multipleService categories represented

Policy excerpt: Part 1 — scope & routing

Prior authorization / coverage routing & criteria

Prior Authorization / AIM referral requirements (per-code entries)

Covered CPT and HCPCS codes listed below may require prior authorization through AIM or via Blue Cross Blue Shield of New Mexico direct prior authorization pathways. Where present, AIM-managed codes require submission through the AIM portal or phone prior to scheduling. Per-code operational and documentation requirements follow.

Branch: Prior Authorization / AIM referral requirements (per-code entries)

- Codes managed by AIM require referral via the AIM portal or by calling the AIM line prior to service.

- Codes not managed by AIM require prior authorization via BCBSNM prior authorization workflows (phone/portal) as indicated in code-level notes.

- Some codes include explicit add/remove effective dates; those dates control the period the prior authorization requirement applies. See code-level status notes for effective date details.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2023 New Mexico Medicaid Procedure Codes Requiring Prior Authorization

Policy CodePolicy N/A

Change TypeMultiple code additions and removals (per-code)

Effective Date

Next Review Date

SourceLink

On This Page

Per-code documentation / requirement

Per-code documentation and requirement details (grouped; transplant-specific branch retained). Each leaf preserves operational notes such as whether transplant approval is distinct from routine prior authorization.

ALL of the following

Surgical supply and procedure codes (examples below) — required documentation: pre-operative evaluation, complete History & Physical including description of functional impairment, and operative report.
Examples in this policy: CPT 11920, 11921, 11922, 11950 (see code-level entries).
Transplant-related codes
- Transplant codes require surgical documentation plus explicit transplant program approval (when applicable).
  Transplant program approval is managed separately from AIM — authorization may be documented as 'transplant approved' vs 'no approval' depending on program decision.
- When transplant approval is NOT obtained or not required, standard prior authorization and medical records (H&P, operative report) still required.
Cosmetic vs reconstructive procedures: documentation must support medical necessity per referenced SUR policy numbers (e.g., SUR716.001, SUR716.011).
Codes with Cosmetic/Reconstructive policy references require alignment with those clinical policies for authorization.

Per-code prior authorization and documentation requirements

Operational and billing-level prior authorization and documentation requirements by code — consolidated and non-duplicative. This block preserves code-level status notes (AIM-managed flag, required documents, policy cross-references, and effective/add/remove dates when listed).

ANY of the following

CPT 11920 — Required: Pre-operative evaluation, History & Physical including functional impairment, and operative report.
Category: Outpatient Medical and Surgical Services. Clinical criteria hierarchy: BCBSNM Medical Policy MCG. Medical Policy Numbers: SUR716.001, SUR716.011. Change date: Added prior to 9/1/2019.
CPT 11921 — Required: Pre-operative evaluation, History & Physical including functional impairment, and operative report.
Category: Outpatient Medical and Surgical Services. Clinical criteria hierarchy: BCBSNM Medical Policy MCG. Medical Policy Numbers: SUR716.001, SUR716.011. Change date: Added prior to 9/1/2019.
CPT 11922 — Required: Pre-operative evaluation, History & Physical including functional impairment, and operative report.
Category: Outpatient Medical and Surgical Services. Clinical criteria hierarchy: BCBSNM Medical Policy MCG. Medical Policy Numbers: SUR716.001, SUR716.011. Change date: Added prior to 9/1/2019.
CPT 11950 — Required: Pre-operative evaluation, History & Physical including functional impairment, and operative report (per code record).
Category: Outpatient Medical and Surgical Services. See clinical policy references and code-level notes for any AIM management flag or effective dates.

Prior Authorization Requirement

General prior authorization requirement summary and provider actions.

- Prior Authorization Requirement: Many listed codes require prior authorization before the service is rendered. Confirm pathway: AIM portal/phone when code is AIM-managed (green-highlight in master list) or BCBSNM prior authorization when not AIM-managed.

- Documentation: For surgical/procedural codes, include pre-operative evaluation, H&P with functional impairment, and operative report. Additional policy-specific documentation may be required where clinical policy IDs are referenced (e.g., SUR716.001, SUR716.011).

- Billing/authorization: Submit all required documentation at time of authorization request to avoid denials or retrospective review.

OpenPayer

2023 New Mexico Medicaid Procedure Codes Requiring Prior Authorization

Policy excerpt: Part 1 — scope & routing

Prior authorization / coverage routing & criteria

What clinicians and coders must do

Code lists in this part

Key terms & abbreviations

Common billing & operational questions (FAQ)

Policy changes & code status timeline