Procedure code list with utilization management designations (MP Criteria / Non‑covered / EIU / Recommended Clinical Review)
A multi-page code listing used by Blue Cross Blue Shield - New Mexico indicating, for each CPT/HCPCS/procedure code, the plan-level coverage designation (Medical Policy Criteria requiring review/predetermination, Non‑Covered, Experimental/Investigational/Unproven (EIU), or Unlisted/Undefined) and effective/ending dates. Applies to services on or before 2024-01-01 unless otherwise noted; updated December 2024.
Some codes (e.g., 93150-93153) have date ranges showing a temporary MP Criteria window (2024-02-15 to 2024-05-14) and then EIU not reimbursed status effective 2024-05-15.
Policy Overview & Scope
General Utilization Management Designations
Date-windowed classification changes (operational note): Codes in this master list can change classification on specific effective dates. When a code transitions between designations (for example, from MP Criteria to EIU or from Non Covered to MP Criteria) the policy applies the designation that is effective for the date of service. In practice this means: submitters must check the code-level effective and ending dates recorded in this policy and, when in doubt, request a recommended clinical review (predetermination) to confirm coverage for services near a transition window.