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).
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.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.