Blue Cross Blue Shield NM Plastic/Reconstructive Coverage

Coverage designations and criteria

Code group coverage labels

Coverage designations in this extract are by code group labels

MP Criteria: Procedures/services reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

See definition and repeated entries across the code list (e.g., chunk 2, chunk 1).

Non Covered: Procedure/service not covered by the Plan; not subject to pre-service review.

Codes explicitly labeled Non Covered will be denied as not covered (see chunk 2).

EIU: Experimental, Investigational, Unproven — Procedure/service not reimbursed by the Plan; not subject to pre-service review.

EIU entries reference the Clinical Payment and Coding Policy (CPCP) (see chunk 1).

Unlisted: Procedure/service not specifically defined or classified; may be subject to contract or clinical review.

Unlisted codes frequently require documentation and may trigger contract/clinical review (see chunk 1).

Coverage flags by code

Coverage and review instructions (by code) in this excerpt

MP Criteria codes: Codes labeled 'MP Criteria' require submission for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

See many MP Criteria code lines (examples in chunks 18, 31).

EIU codes: Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review.

Examples and instruction present across the list (see chunk 18).

Unlisted codes: Unlisted procedure codes are not specifically defined or classified and may be subject to contract or clinical review.

Multiple unlisted codes appear; provide documentation when submitting (see chunk 31).

Non Covered codes:

General coverage/review instructions

Coverage and review instructions tied to listed codes

MP Criteria requirement: For codes marked 'MP Criteria', procedures/services are reviewed against Medical Policy Criteria and providers should submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Explicit MP Criteria instruction appears with many CPTs (see chunks 36, 48, 55).

EIU designation: Codes marked 'EIU' are identified as not reimbursed by the Plan and not subject to pre-service review; check EIU policy in the Clinical Payment and Coding Policy (CPCP).

Multiple EIU examples in the extract (see chunks 40, 48).

Unlisted/Undefined procedures: Unlisted or undefined procedures may be subject to contract or clinical review and recommended clinical review/predetermination is suggested to avoid post-service review.

Unlisted entries are frequent (see chunks 36, 40).

Coverage designations and administrative requirements

Coverage designations and required administrative steps for listed CPTs

Predetermination recommended: For codes listed as 'MP Criteria', submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

See vascular, stem cell, bariatric and other listed MP Criteria codes (chunks 54, 56, 58, 68).

EIU designation: Codes labeled EIU are procedures not reimbursed by the Plan and not subject to pre-service review; check the EIU policy in the Clinical Payment and Coding Policy (CPCP).

Examples scattered through the list (chunks 40, 64, 66).

Non-covered dental/gum procedures: Several dental/gum CPTs (41820, 41822, 41823, 41828, 41830, 41870, 41872, 41874) are explicitly labeled Non Covered.

Dental/gum codes are labeled Non Covered in the extract (chunks 61–64).

Submission and reimbursement conditions

Covered when submission meets Medical Policy criteria and recommended clinical review/predetermination is obtained as indicated

MP Criteria submission: Procedures/services labeled 'MP Criteria' must be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Applies to multiple CPTs listed with MP Criteria across the document (chunks 74, 77).

EIU designation: Procedures/services designated EIU are not reimbursed by the Plan and are not subject to pre-service review.

Examples of EIU-designated procedures are present in the list (see chunk 80).

Code-level coverage statements

Coverage designations noted per code

MP Criteria codes: Procedures/services reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Many specific CPTs list this designation (see chunks 90, 98, 106).

EIU codes (Excluded/Not reimbursed): Codes labeled 'EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.'

Laboratory and procedure codes are annotated EIU in the list (chunks 107, 109).

Unlisted codes: Unlisted procedure codes are noted as 'maybe subject to contract/clinical review.'

Unlisted entries (e.g., 64999, 66999) appear across the document (chunk 90).

Non-covered examples:

Per-code coverage status

Coverage status assignments as listed

EIU non-reimbursed: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.'

EIU lab and procedure codes are listed (chunks 109, 121).

Non Covered: Codes labeled 'Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review.'

Autopsy and other non-covered codes are listed (chunks 116, 119).

Unlisted: Codes labeled 'Unlisted: Procedure/service not specifically defined or classified, maybe subject to contract/clinical review.'

Unlisted pathology and other codes require review (chunk 121).

MP Criteria (predetermination): Codes labeled 'MP Criteria: Procedures/services reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.'

Coverage classifications present

Coverage classifications shown (examples):

Non Covered: Procedures/services explicitly labeled 'Non Covered' are not payable by the Plan.

Examples in the excerpt include behavioral health and vaccine entries (chunk 126, 131).

EIU: Items labeled 'EIU' are not reimbursed by the Plan and reference the EIU/CPCP policy.

Multiple diagnostic and assay codes are annotated EIU (chunks 129–131).

MP Criteria (Predetermination recommended): Items marked 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Examples include neurostimulation, biofeedback and certain diagnostic studies (chunk 129).

Coverage annotations in excerpt

MP Criteria codes: Services listed as 'MP Criteria' require review against Medical Policy Criteria; submission for Recommended Clinical Review (Predetermination) is advised to avoid post-service review.

Examples: continuous EEG/Veeg codes and other neurologic monitoring codes (chunk 144, 150).

EIU codes: Services labeled 'EIU' are not reimbursed by the Plan (check EIU policy/CPCP).

Examples in neurology and rehabilitation sections (chunk 150, 155).

Non Covered codes: Services explicitly marked 'Non Covered' are not covered by the Plan and are not subject to pre-service review.

Non Covered therapy and athletic training codes appear in this section (chunk 155).

Unlisted codes: Unlisted procedures may be subject to contract/clinical review and may require submission of clinical documentation; prior authorization may be required per contract for some unlisted modalities.

Per-code coverage determinations

Coverage determinations by code

EIU not reimbursed: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and not subject to pre-service review.

Category includes many temporary/T and other codes (chunks 199–201).

MP Criteria - Predetermination recommended: Codes reviewed against Medical Policy Criteria should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Examples include advanced procedure codes and CAR-T related codes (chunk 212).

Per-code coverage stance

Coverage stance is per-code as listed below

EIU_not_reimbursed: Codes marked 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed; not subject to pre-service review per table.

Examples across chunks 216–235 include numerous T-codes and others (see chunks 216, 234–235).

MP_Criteria_predetermination: Codes marked 'MP Criteria' require submission for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Many temporary and CAR-T related codes are annotated MP Criteria (chunks 212, 216, 234).

Per-code coverage designations

{operator:'any', n:1, label:'EIU / Not reimbursed', text:'Codes labeled EIU are not reimbursed by the Plan and are not subject to pre-service review; see CPCP EIU policy for details.', threshold:'', note:'Examples: A0426, A2015, many A2xxx codes and T-code entries in chunks 234–245', children:[]}

{operator:'any', n:1, label:'Non Covered', text:'Codes explicitly marked Non Covered are not covered by the Plan and are not subject to pre-service review.', threshold:'', note:'Examples: A4890, 213HA series and other Non Covered HCPCS/CPT entries (chunks 240, 253)', children:[]}

{operator:'any', n:1, label:'MP Criteria (Predetermination recommended)', text:'Codes marked MP Criteria are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination) to avoid post-service review.', threshold:'', note:'Examples: 0776T–0779T series, 0781T–0783T, 0803T, select A04xx codes (chunks 234–245).', children:[]}

Codes explicitly labeled Non Covered in the list are excluded from reimbursement by the Plan. Examples from the excerpt include 07957, 11200, and 11201, each annotated as “Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review.”

Certain codes are explicitly identified as Non Covered and others are marked EIU (Experimental/Investigational/Unproven) and therefore not reimbursed. Examples include 21248 and 21249 (Non Covered) and 17340 (EIU: not reimbursed by the Plan).

Procedures labeled EIU are not reimbursed by the Plan and are not subject to pre-service review. Example EIU entries in the excerpt include codes such as 28890, 30468, and 30469.

Multiple dental/gum procedure CPTs are explicitly labeled Non Covered. Examples shown in the list include 41820, 41822, 41823, 41828, 41830, 41870, 41872, and 41874.

Several procedures designated EIU in the extract are identified as not reimbursed by the Plan. Examples include head/neck and upper‑GI related entries such as 41530, 43206, 43252, 43290, 43291, and 46707.

The document repeatedly marks groups of procedures as EIU, confirming that such designated services are not reimbursed by the Plan. Sample EIU-labeled codes in the extract include 61630, 62263, 62264, and other listed examples.

Multiple services are annotated EIU and therefore excluded from payment. The list includes laboratory and specialty procedures (for example, 82523, 83695, 83722, 83937) that are explicitly described as “EIU: Procedure/service not reimbursed by the Plan.”

Entries labeled EIU are described as not reimbursed and not subject to pre-service review; entries labeled Non Covered are not covered by the Plan and not subject to pre-service review. Multiple code lines in the excerpt use those designations, indicating explicit exclusion from reimbursement.

Autopsy and related procedure codes in the 88000–88099 range are explicitly listed as Non Covered and therefore not subject to pre-service review or reimbursement by the Plan (examples: 88027, 88028, 88036, 88037, 88040, 88045, 88099).

Across the excerpt, any code explicitly designated Non Covered or labeled EIU is excluded from reimbursement — Non Covered indicates the service is not covered by the Plan, while EIU denotes experimental or unproven services that are not reimbursed.

The extract contains numerous explicit Non Covered and EIU annotations. Codes so labeled are excluded from coverage in this document fragment and are identified as not payable or not reimbursed by the Plan.

Many listed codes are clearly annotated as either Non Covered: Procedure/service not covered by the Plan or EIU: Procedure/service not reimbursed by the Plan. These labels indicate explicit exclusion from payment and note that such items are not subject to pre-service review.

A large set of U‑codes in the extract (for example 0113U, 0114U, 0118U, 0129U, 0130U) are annotated Non Covered and therefore are not reimbursed by the Plan; some entries also advise that prior authorization may apply per contract.

Multiple temporary (T) and U codes in the list are labeled EIU (not reimbursed by the Plan). The excerpt shows several T/U entries where the Plan indicates EIU: Procedure/service not reimbursed by the Plan and therefore not subject to pre-service review.

Services explicitly marked EIU in the document extract are not reimbursed by the Plan. The repeated EIU annotations confirm these services are excluded from payment under the Plan’s stated coding guidance.

Several codes throughout the T‑code series and related listings are marked EIU or MP Criteria. Items annotated EIU are not reimbursed by the Plan and would be denied if billed; items marked MP Criteria require submission for Recommended Clinical Review (predetermination) to avoid post-service review.

Many codes in the excerpt are individually annotated as either Non Covered or EIU. When a code is labeled Non Covered it is not payable; when labeled EIU it is considered experimental/investigational and not reimbursed by the Plan.

The document lists procedure 17340 as an example of a CPT explicitly marked EIU with the statement: “EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.”

Code 41820 (Excision Gum Each Quadrant) is annotated in the excerpt as Non Covered — i.e., “Procedure/service not covered by the Plan. Not subject to pre-service review.”

Code 65760 (Revision of cornea) is explicitly labeled Non Covered in the list: “Procedure/service not covered by the Plan. Not subject to pre-service review.”

Certain SARS‑CoV‑2 antibody and related assay codes are annotated in the excerpt as Non Covered or EIU. Examples include 86910 and 86911, shown with EIU and/or Non Covered designations and effective date notes where indicated.

Entries in the list explicitly use the label Non Covered to denote that a procedure or service is not covered by the Plan; such items will be denied if billed under the Plan’s rules.

The excerpt shows many items labeled Non Covered or Unlisted; items so marked are not covered and unlisted procedures may be subject to contract or clinical review. The document’s lists do not provide additional NMN narrative beyond those explicit labels.

CPT / HCPCS code groups and listings

Listed CPT/HCPCS codes (MP Criteria / EIU / Not Covered)mixed

0220T	Transcatheter pulmonary valve implantation (experimental/temporary listings)
0221T	Transcatheter pulmonary valve implantation, additional (experimental/temporary listings)
0264T	Insertion or replacement of neurostimulator pulse generator, rechargeable (MP Criteria)
0265T	Insertion or replacement of neurostimulator pulse generator, non-rechargeable (MP Criteria)
0668T	Transcatheter device placement (category III / temporary)
0669T	Transcatheter device removal (category III / temporary)
0670T	Transcatheter device revision (category III / temporary)
0672T	Transcatheter device interrogation/programming (category III / temporary)
0743T	Transcatheter valve procedure, investigational/temporary listing
0746T	Transcatheter valve repair, investigational/temporary listing

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Plastic / Reconstructive Surgery codes (MP Criteria)CPT

11950	Tx contour defects 1 cc or less - MP Criteria
11951	Tx contour defects 1.1-5.0 cc - MP Criteria
11952	Tx contour defects 5.1-10 cc - MP Criteria
11954	Tx contour defects >10 cc - MP Criteria
19350	Breast reconstruction - MP Criteria
19499	Unlisted procedure, breast - MP Criteria

Unlisted / Unspecified (Plastic/Recon)mixed

15999

Unlisted procedure (pressure ulcer) - Unlisted; subject to clinical review

What providers must do (predetermination, PA, documentation)

Prior Authorization

Predetermination / Prior Authorization expectations

Providers must submit procedures/services that are reviewed against Medical Policy Criteria (MP Criteria) for a Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS. Predetermination (recommended clinical review) is strongly advised for MP Criteria items and many unlisted/temporary codes. Some services that are subject to MP Criteria may also require prior authorization depending on the member's contract; check the member benefit booklet or contact customer service.

Submit MP Criteria items for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.
Predetermination is recommended for unlisted procedure codes (e.g., 64999, 21299, 29999, 30999, 31299, 88399, 89240, 89699) and for temporary/new codes until coverage is confirmed.
If a code is marked MP Criteria and the member’s contract requires prior authorization, follow both predetermination and PA as indicated by the contract.

Prior Authorization

Prior Authorization / Predetermination for transplant/harvest procedures

Certain transplant-related and stem cell harvest procedures are designated MP Criteria and should be submitted for Recommended Clinical Review (Predetermination). Prior authorization may be required per contract for transplant/harvest services; note that PA status for specific codes changed effective 9/18/2023 (many had PA added per contract on 9/18/2023 and some PA requirements were later removed effective 9/18/2023).

Context and scope notes

This document fragment provides administrative coding and review guidance only. It contains no clinical background on disease processes or treatments; its focus is on per-code coverage designations and related administrative recommendations for providers submitting claims to Blue Cross Blue Shield - New Mexico.

Key term definitions

MP Criteria definition

Definition: MP CriteriaProcedures/services reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination) to avoid post-service review by BCBS.

Provider actionSubmit predetermination via Utilization Management/Availity when codes are labeled MP Criteria.

Reference noteSee code list entries and chunk text for MP Criteria designation and submission guidance.

EIU definition

Definition: EIUExperimental, Investigational and Unproven (EIU): Procedures/services not reimbursed by the Plan; not subject to pre-service review.

Reference guidanceCheck the EIU policy in the Clinical Payment and Coding Policy (CPCP) for details.

Document changes and dates

2023-09-18prior_authorization_changeLatest

Prior authorization requirement removed for listed codes (PA removed effective 9/18/2023).

2023-06-01code_effective_date_added

CPT 43632 was added/effective 06/01/2023 and is listed as MP Criteria requiring Recommended Clinical Review (Predetermination).

2023-01-01code_effective_date_added

OpenPayer

Plastic/Reconstructive Surgery — Procedure Code Group Coverage & Submission Guidance (coverage criteria)