Blue Cross Blue Shield NM plastic surgery Coverage

Coverage categories present in list

Coverage stance is determined per code as follows

MP Criteria / Predetermination: Codes mapped to 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review.

See referenced SUR policies (e.g., SUR716.001, SUR705.029) for specific clinical criteria.

Non Covered: Codes explicitly labeled 'Non Covered' are not a benefit under the Plan and are not subject to pre-service review.

Examples: entries in the list flagged 'Non Covered' (see code-level rows).

EIU: Codes designated Experimental, Investigational, and/or Unproven (EIU) are not reimbursed by the Plan and are not subject to pre-service review.

EIU references the Clinical Payment and Coding Policy (CPCP/ADM1001.032).

Administrative coverage mapping (codes -> policy references / handling)

Coverage and administrative handling as indicated for listed procedures

Predetermination Recommended: Many listed procedures are described as 'reviewed against Medical Policy Criteria' and instruct 'Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.'

Determine applicable SUR/SUR7xx policy referenced in the code row when preparing submission.

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

These are excluded from reimbursement per the listing and reference the EIU/CPCP policy.

Prior Authorization: Certain entries note 'Prior Authorization may be required per contract agreement'; PA requirements depend on the member's contract and should be confirmed in benefits/authorization systems.

If a code row includes a PA note, verify contract-specific PA rules prior to scheduling.

Coverage annotations summary

Coverage annotations in these chunks fall into recurring categories:

MP Criteria / Recommended Clinical Review: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review; prior authorization may be required per contract.

Many reconstructive and implant procedures are routed to SUR/SUR7xx policies.

EIU / Not reimbursed: Entries marked EIU indicate the procedure/service is not reimbursed by the Plan and not subject to pre-service review.

Examples include selected devices, laboratory assays, and novel procedures referenced to ADM1001.032/CPCP.

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

These entries are explicit exclusions and will not be paid if billed.

Coverage routing and necessity guidance

Routing and coverage stance for listed procedure codes:

Predetermination required when indicated: When a code entry includes 'MP Criteria' and references a SUR policy, submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Prepare clinical documentation referencing the named Medical Policy for submission.

EIU / Non‑reimbursed procedures: If a code is marked 'EIU' the procedure/service is not reimbursed by the Plan and is not subject to pre-service review.

Do not submit for predetermination expecting coverage; check EIU/CPCP policy for exceptions.

Unlisted procedure handling: Unlisted procedure codes may be subject to contract/clinical review and should be submitted for Recommended Clinical Review when mapping notes indicate 'MP Criteria'.

Unlisted code rows frequently indicate may require prior authorization per contract.

Coverage contingent on Medical Policy review / predetermination

Covered when reviewed against referenced Medical Policy criteria and predetermination is obtained where recommended

Medical Policy review required: Procedure/service must be reviewed against referenced Medical Policy criteria (for example SUR703.002 and related SUR703.* policies for HCT-related codes).

Predetermination recommended to avoid post-service review; prior authorization may be required per contract.

MP Criteria / Predetermination

Procedures designated 'MP Criteria' in the list

MP Criteria: Procedure/service reviewed against Medical Policy Criteria.

Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Excluded / Not Reimbursed (EIU)

Procedures designated 'EIU' or 'Experimental/Not reimbursed'

EIU/Experimental: Procedure/service is EIU: not reimbursed by the Plan or is listed as Experimental/Investigational and/or Unproven.

These entries are not subject to pre-service review and will not be paid; check ADM1001.032/CPCP for policy details.

List-level coverage actions

Coverage actions shown in list entries

MP Criteria entries: Procedures marked 'MP Criteria' are subject to medical policy review and predetermination is recommended.

Referenced policy numbers (SUR/SUR7xx) contain the clinical medical necessity criteria.

EIU entries: Procedures labeled 'EIU' are not reimbursed by the Plan.

These are excluded from coverage per the list.

Unlisted codes: Unlisted CPT codes may require contract/clinical review and prior authorization per contract; coverage is determined case-by-case.

Submission for Recommended Clinical Review is advised when the row references MP Criteria.

Coverage handling summary

Coverage handling as stated in the code list segment:

Predetermination recommended for codes reviewed against Medical Policy Criteria: When a procedure/service is reviewed against Medical Policy Criteria the document instructs to submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Applies to codes annotated 'MP Criteria' in this segment.

Unlisted procedure handling: Unlisted CPT codes are noted as 'may be subject to contract/clinical review' and should be submitted for review/predetermination as indicated.

Unlisted codes often require additional documentation and may trigger post-service review or denials.

EIU / Not reimbursed: Codes annotated EIU are not reimbursed by the Plan and are not subject to pre-service review; consult the referenced CPCP/ADM1001.032 for details.

Examples include selected laboratory assays and device codes.

Coverage routing and reimbursement stance

Coverage and review routing notes present for listed codes:

MP Criteria routing: If a code is marked 'MP Criteria' it is reviewed against a named Medical Policy Criteria and providers should submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Examples in these chunks include reproductive medicine and specialty pathology codes.

Non Covered: Codes marked 'Non Covered' are not reimbursed by the Plan and are not subject to pre-service review.

Examples: selected cryopreservation entries and some laboratory items.

EIU / Not reimbursed: Codes marked 'EIU' or explicitly 'not reimbursed by the Plan' are not reimbursed; providers should reference the referenced EIU/CPCP policies for details.

These entries may include novel tests and device therapies.

Coverage categories present in excerpt

Coverage actions in this excerpt are per-code and fall into two principal categories:

EIU_not_reimbursed: Procedure/service explicitly stated as not reimbursed by the Plan and not subject to pre-service review.

Examples: multiple Category III/T-codes and other entries flagged EIU/ADM1001.032.

MP_Criteria_predetermination: Procedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Examples: selected ophthalmologic and glaucoma device codes (e.g., 0450T, 0474T) and other SUR-referenced codes.

MP Criteria / Predetermination

Covered only when reviewed per Medical Policy (predetermination recommended):

MP Criteria submission requirement: Submit for Recommended Clinical Review (Predetermination) to avoid post-service review for codes annotated 'MP Criteria'.

Applicable to multiple T-code and HCPCS entries that reference a SUR or MED policy.

Experimental / Not reimbursed

Not reimbursed when classified as Experimental/Investigational/Unproven:

EIU/Experimental designation: Procedure/service annotated as EIU or ADM1001.032 is not reimbursed by the Plan and is not subject to pre-service review.

Examples: auto-quantification plaque analysis T-codes (0624T–0626T) and other ADM1001.032 entries.

Coverage designations in this section

Codes in this part are assigned one of the following plan designations

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

Examples: HCPCS A2014–A2018, C9257 mapped to SUR704.012 or related policies.

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

Examples: A4100, C9354, C9356 flagged EIU under SUR704.012/ADM1001.032.

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

Examples: A4458, A4520, A4554 labeled Non Covered in this section.

Unlisted or NOC entries may be subject to contract or clinical review.

Codes labeled Non Covered in the procedure list are explicit plan exclusions. When an entry shows "Non Covered: Procedure/service not covered by the Plan: Not subject to pre-service review," the service is not a benefit and claims for that code are at high risk of denial (examples: 11200 shown as Non Covered).

Entries marked EIU (Experimental, Investigational and/or Unproven) state that the "Procedure/service not reimbursed by the Plan: Not subject to pre‑service review." Procedures with this annotation are excluded from reimbursement and are not payable by the Plan.

Examples of codes explicitly labeled Non Covered or EIU appear throughout the list — for instance, 21248 and 21249 include a Non Covered label alongside MP routing notes, and 28890 is listed as EIU with a statement that the procedure/service is not reimbursed by the Plan.

Procedures annotated EIU are described consistently as not reimbursed by the Plan and not subject to pre‑service review; the listing language treats EIU-labeled services as excluded from payment.

Some codes are explicitly labeled Non Covered or as Unlisted and the list states these are not subject to pre‑service review. For example, 41820–41823 are shown as Non Covered, and several unlisted codes are flagged as potentially subject to contract/clinical review rather than predetermination.

Codes marked EIU or described as Experimental (e.g., 41530, 43206, 43290, 43291 in the list) are stated as "Procedure/service not reimbursed by the Plan," and therefore are not payable.

Entries with the annotation 'EIU: Procedure/service not reimbursed by the Plan' reflect an explicit exclusion: such entries are excluded from reimbursement and the Plan will not pay claims for those codes.

Code 65760 (Revision of cornea) is explicitly labeled Non Covered in the list, indicating it is an excluded service and not subject to pre‑service review.

The segment includes many specific codes labeled Non Covered or EIU (for example, laboratory assays such as 82523 marked EIU, and blood‑typing/autopsy codes like 86910 and 88014 marked Non Covered), which indicate explicit noncoverage for those items.

Specific codes are explicitly listed as Non Covered in the document (for example multiple autopsy codes and spectacle fitting codes shown as Non Covered); these entries are plan exclusions and claims will not be reimbursed.

Multiple CPT codes across the listing are identified with either EIU or Non Covered status (the list shows several individual examples such as 93702 flagged EIU and other entries flagged Non Covered), reinforcing that these annotations denote services that are not reimbursed.

Codes marked EIU are repeatedly identified as procedures/services not reimbursed by the Plan and not subject to pre‑service review; the list uses this flag to indicate exclusion from payment.

Several U‑codes in the listing are annotated Non Covered (for example, a set of sample U codes such as 0131U–0136U are shown as Non Covered), which denotes explicit exclusion from coverage for those proprietary/test codes.

Codes annotated under ADM1001.032 (the Experimental; Investigational and/or Unproven Procedures/Services policy) are treated as EIU and the list indicates these procedures/services are not reimbursed by the Plan.

Items explicitly labeled Non Covered appear among HCPCS A‑codes and other supply codes (examples include A4458, A4520, A4554), demonstrating that device and supply entries marked Non Covered are excluded from coverage.

Procedures and devices shown with EIU designations (for example C9354, C9356, C9358, C9360, C9363, C9364 and several E‑codes like E0221, E0231, E0232) are listed as not reimbursed by the Plan and not subject to pre‑service review.

The list contains many entries for D‑ and E‑codes that are explicitly marked Non Covered (for example dental codes such as D7210–D7230 shown as Non Covered), indicating those services are excluded from benefits.

At least one code in the list is explicitly labeled Experimental/Investigational/Unproven (EIU) in text (examples include lab assays such as 82523 and other entries), and the list describes EIU entries as investigational/unproven and not reimbursed.

Entries identified as EIU are described as investigational/unproven and the list uses that designation rather than traditional 'Not Medically Necessary' wording; EIU entries are not reimbursed by the Plan.

Example codes marked EIU in the list include C9358, C9360, C9363 and C9364 (dermal and bioengineered skin substitutes) which the listing shows as not reimbursed by the Plan under SUR704.012.

The example code 65760 is called out in the list as Non Covered, reinforcing that some ophthalmology procedures are explicit exclusions.

A segment of the list identifies tests and procedures as not reimbursed (EIU) or Non Covered, but the entry does not include detailed clinical 'Not Medically Necessary' criteria — instead it maps codes to EIU or MP labels and references the applicable medical policies or CPCP.

The document consistently uses the labels Non Covered, Unlisted, EIU and MP Criteria; it does not generally use the phrase 'Not Medically Necessary' within the code rows but conveys exclusion or MP review via these designated annotations.

Codes labeled EIU are treated as not reimbursed and the list language specifies they are "Procedure/service not reimbursed by the Plan: Not subject to pre‑service review," making EIU the operative exclusion designation in the document.

Procedures annotated as not reimbursed by the Plan (EIU) appear throughout and the Plan treats those entries as non‑payable when billed; the listing therefore flags such services to avoid payment expectation.

Codes tied to EIU and to policy ADM1001.032 are explicitly treated as not reimbursed in the list; ADM1001.032 is cited as the Clinical Payment and Coding Policy for Experimental/Investigational/Unproven Procedures/Services that underlies those exclusions.

What providers must do

Documentation Required

Documentation and submission pathway

This procedure code list identifies services that may be subject to medical policy review, predetermination (Recommended Clinical Review), prior authorization per contract, or may be non-covered/experimental. Providers should submit requests for Recommended Clinical Review (predetermination) through the payer's Utilization Management pathways (see Availity) when listed as MP Criteria to avoid post-service denials. When a code is marked EIU (Experimental, Investigational, Unproven), it is generally not reimbursed and is not subject to pre-service review. Unlisted codes may trigger contract or clinical review; obtain predetermination when uncertain.

Submit Recommended Clinical Review (Predetermination) for codes listed as MP Criteria to avoid post-service review.
Prior Authorization may be required per contract for certain codes — check member benefits and obtain authorization when indicated.
For codes marked EIU (Experimental, Investigational, and Unproven) or Non Covered, do not expect reimbursement; these are not usually subject to pre-service review.
Unlisted/undefined procedure codes (eg, 17999, 20999, 22899, 30999, 32999, 33999, 37999, 51999, 67999, 69949, 69979, 76496, 81479, 81599, 89398, etc.) may require predetermination or contract review — submit supporting clinical documentation.
For procedure codes associated with specific medical policies (e.g., SUR716.001, MED202.003, SUR703.002, SUR7O5.023, MED2O1.017, MED2O5.008), include the relevant clinical justification and reference the medical policy number in the submission.
Use predetermination for implant/device and monitoring/testing codes (examples in the list) as these often require prior authorization per contract.
Submit complete supporting clinical documentation when requesting review: indication, prior treatments, diagnostic testing, and any policy-specific criteria.
Use Availity or the payer's Utilization Management portal to submit predetermination/prior authorization requests.

Prior Authorization

Prior Authorization May Be Required

Certain codes in this list carry an explicit recommendation that prior authorization may be required per the member's contract. Always verify benefit and authorization requirements before rendering services to avoid denials.

Examples where Prior Authorization may be required per contract: codes noted with 'Prior Authorization may be required per contract agreement' such as 21146, 21147, 21159, 21160, 38206, 38230, 38241, 69714, 69717, 69930, 91117, 93228/93229, 93797/93798, 99183, E0485/E0486, and others as indicated in the list.
When prior authorization is required by contract, obtain authorization in advance using the payer's UM process.

Documentation Required

Predetermination Recommended (reference to specific medical policies)

When a procedure is reviewed under Medical Policy Criteria (MP Criteria), predetermination (Recommended Clinical Review) is advised. Submissions should include the specific medical policy identifier to facilitate review.

MP Criteria examples: SUR716.001, SUR716.009, SUR703.002, SUR7O5.023, MED202.003, MED2O1.017, MED2O5.008, SUR7O7.016, SUR714.003, SUR703.043, and many others listed alongside codes.
Predetermination is recommended for MP Criteria-coded procedures (submit policy number and supporting documentation).

Prior Authorization

Predetermination / Prior Authorization may be required

Many procedures in this list are subject to medical policy criteria review and may require predetermination; unlisted or EIU codes carry higher denial risk if not reviewed in advance. Submit supporting clinical documentation with all requests.

Subject to Medical Policy Criteria review — submit for Recommended Clinical Review (Predetermination) to avoid post-service review for MP-coded items.
Denial triggers include unlisted codes and EIU-coded items if not supported by appropriate documentation or a prior predetermination.
Examples of codes where predetermination/prior authorization may be required or recommended: 21188, 21206, 21208, 21248, 21249, 21299, 21685, 22505, 23929, 24300, 25259, 26340, 27299, 27703, 27860, 28890, 29866, 29914-29916, 30468-30469, 30999, 31299, 31599, 31899, 32994-32998, 33211, 33267-33275, 33285, 33418-33419, 33542, 33999, 36299, 36465-36471, 36473-36483, 36516, 36836-36837, 37215-37217, 38206-38211, 38230-38241, 38242, 38299, 38999, 39499, 39599, 40799-40899, 41530, 41820-41823, 43206-43252, 43284, 43775, 43842-43847, 51999, 52327, 52441-52442, 53855, 54405, 54660, 54699, 55559, 55880, 61999, 62287, 64582, 64628-64629, 64640, 67900-67908, 67999, 69706-69730, 69930-69979, 76496, 80299, 81099, 81479, 81599, 82523, 83006, 83695, 83698, 83701, 83704, 83722, 83937, 83987, 88014-88029, 88399, 88749, 89240, 89258-89259, 89335, 89346-89398, 90378, 91117, 93228-93229, 93660, 93702-93740, 93797-93798, 95705-95715, 99183, 99199, 99360, 99429, 99446-99447 and many T-/U-/C-/A- code ranges.
When in doubt, obtain predetermination to reduce post-service denials.

Billing Rule

Predetermination / Prior Authorization for HCPCS A/C codes

The list includes device/implant, HCPCS A/C codes, and drug/biologic codes that may require predetermination or prior authorization. For HCPCS items, check whether the code is listed as EIU, Non Covered, Unlisted, or MP Criteria and follow the corresponding submission guidance.

HCPCS A/C examples: A2014, A2015, A2018, A4100, A4335, A4421, A4458, A4520, A4553-4555, A4575, A6549, A9150-9153, A9270-9279 — review list annotations for EIU/Non Covered/MP Criteria.
C-codes and J-codes such as C9257, C9354, C9356, C9399, C9739-C9740, C9757, C9764 may have MP Criteria or prior authorization requirements.
Submit predetermination with device/implant documentation (indication, device model, manufacturer information) when codes are associated with implantable devices.

Documentation Required

Predetermination recommended for monitoring/testing codes

Predetermination is recommended for monitoring, telemetry, EEG, and other diagnostic testing codes that reference a medical policy. Include diagnostic reports and indication when submitting.

Monitoring/testing codes: 33285, 93228, 93229, 93797, 93798, 95705-95715, 91117, 91132-91133, 93702, 93740, 93797-93798, 93660, 93228-93229 — submit for Recommended Clinical Review when listed as MP Criteria.
Provide test reports, clinical history, and rationale linking the test to medical necessity.

Denial Risk

Predetermination / Prior Authorization

Some codes are explicitly labeled Experimental, Investigational and Unproven (EIU) or Non Covered. These are typically not reimbursed under the plan and are not subject to pre-service review. Providers should counsel members accordingly and consider alternate covered treatments.

EIU/Not reimbursed examples: 07957, 20983, 20985, 22526-22527, 22869-22870, 28890, 30468-30469, 36473, 36836-36837, 41530, 43206/43252/43290-43291, many T-codes (eg, 0120T series), 0062U, 0063U, 0533T-0536T, 0565T-0566T, 0624T-0627T, 0640T-0646T, many A/C/C9 codes noted as EIU in the list.
Do not rely on pre-service approval pathways for EIU-coded items; instead, confirm coverage and discuss financial responsibility with the patient.

Prior Authorization

Predetermination / possible prior authorization required

Unlisted procedure codes and many EIU entries may require additional documentation or may be denied as not covered. When billing unlisted codes, include operative reports, full clinical justification, and consider obtaining predetermination.

Unlisted code examples: 17999, 20999, 22899, 27299, 27599, 27899, 28899, 29799, 29999, 30999, 31299, 31599, 31899, 32999, 33999, 36299, 38999, 39499, 39599, 40799, 40899, 41599, 41530, 41599, 41820-41823, 42999, 43289, 43499, 51999, 54699, 55559, 67999, 69949, 69979, 76496, 80299, 81099, 81479, 81599, 89398, C2699, C9399, and others.
Include procedure details, rationale, and any supporting imaging or pathology when submitting predetermination for unlisted codes.

Key terms and designations

MP Criteria definition

DefinitionMP Criteria: Procedure/service reviewed against Medical Policy Criteria; submission for Recommended Clinical Review (Predetermination) is recommended to avoid post-service review.

ActionSubmit for Recommended Clinical Review (Predetermination) when entry indicates 'MP Criteria' to avoid post-service review.

ReferenceSee linked SUR policies (examples: SUR716.001, SUR703.002) for specific clinical criteria.

Non Covered definition

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

ImplicationClaims for codes labeled 'Non Covered' will not be reimbursed by the Plan.

ExamplesA4458, A4520, A4554 shown as Non Covered in the list.

Experimental, Investigational, Unproven (EIU) definition

DefinitionExperimental, Investigational, and/or Unproven (EIU): Procedure/service not reimbursed by the Plan and not subject to pre-service review.

Policy linkCheck the referenced EIU Clinical Payment and Coding Policy (e.g., ADM1001.032 / CPCP08) for details.

ExamplesMultiple codes (e.g., 17360, 36836, 0624T) are labeled EIU in the list.

EIU short definition

Short formEIU: Procedure/service not reimbursed by the Plan; not subject to pre-service review.

When usedApplied to procedures explicitly flagged as experimental or investigational in the list.

CheckRefer to the EIU/CPCP policy cited for rationale and details.

Unlisted definition

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

ImplicationUnlisted codes often require submission of documentation and may trigger contract/clinical review or predetermination.

Examples17106, 38999, 51999 shown as Unlisted in the list.

EIU definition (alternate chunks)

EIU wording (alternate)Experimental, Investigational and/or Unproven — procedure/service not reimbursed by the Plan and not subject to pre-service review.

ContextUsed for various devices, lab assays, and procedures where Plan lists as EIU (see lab codes 83695, 83701 examples).

Policy referenceCheck the Clinical Payment and Coding Policy indicated (CPCP/ADM1001.032) for applicability.

Recommended Clinical Review (Predetermination) definition

DefinitionRecommended Clinical Review (Predetermination): A recommendation that the provider submit the procedure for clinical review prior to service to avoid post-service review.

When to submitSubmit when the code entry indicates 'MP Criteria' or references a SUR/MED policy.

Submission pathwayRequests can be submitted via the payer website or Availity per instructions in the document header.

Unlisted procedure definition

DefinitionUnlisted procedure: CPT code used when a procedure/service is not specifically defined or classified; may be subject to contract/clinical review and possible post-service denial if not supported.

Provider actionWhen billing unlisted codes, submit supporting clinical documentation and consider predetermination if MP Criteria applies.

Examples38589, 38999, 39499, 51999 are listed as Unlisted in the document.

MP Criteria note

NoteMP Criteria entries instruct providers to submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

ScopeThese notes appear throughout the code list and map codes to specific SUR/MED policy identifiers for clinical criteria.

ActionConfirm member contract benefits and submit predetermination where recommended to reduce denial risk.

EIU designation

DesignationEIU entries are annotated as Experimental; Investigational and/or Unproven (ADM1001.032) and are described as 'Procedure/service not reimbursed by the Plan: Not subject to pre-service review.'

Administrative effectServices labeled EIU will be denied/not payable if billed, absent contract exceptions.

ExamplesMultiple T-code entries (0624T–0627T) are annotated EIU/ADM1001.032.

Unlisted procedure code definition

DefinitionUnlisted procedure code: A CPT code used when a procedure/service is not specifically defined or classified; may be subject to contract or clinical review and often requires submission for Recommended Clinical Review when linked to MP Criteria.

RiskUse of unlisted procedure codes may trigger contract/clinical review and potential post-service denial if not predetermined or supported.

Examples67900, 67999, 38999 shown as Unlisted in the list.

EIU explanation

ExplanationEIU entries indicate 'Procedure/service not reimbursed by the Plan: Not subject to pre-service review' — these items are excluded from reimbursement per the listing.

Where foundApplied to lab assays, novel diagnostics, device implants, and select procedures across the list.

Policy checkRefer to the cited CPCP/ADM1001.032 or other policy IDs for details on rationale.

MP Criteria / Predetermination definition

DefinitionMP Criteria / Predetermination: Procedure/service reviewed against a named Medical Policy and providers should submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

ExamplesCodes mapped to SUR703.* (e.g., 38206) or SUR704.012 (A-codes) in the list instruct predetermination.

ActionInclude clinical documentation referencing the relevant policy when submitting predetermination.

EIU (repeated)

EIU repeatedADM1001.032 appears as the EIU policy reference for many entries—indicating Experimental/Investigational/Unproven status and non‑reimbursement.

ImplicationCodes tied to ADM1001.032 are not reimbursed and not subject to predetermination per the list.

Example codes0624T–0627T, 0640T–0642T group are labeled under ADM1001.032.

EIU (chunk reference)

Chunk refADM1001.032 EIU entries include statements: 'Procedure/service not reimbursed by the Plan: Not subject to pre-service review.'

Practical noteWhen ADM1001.032 is cited, expect denial if billed; do not expect pre-service approval to change EIU designation absent policy change.

Examples0624T, 0625T, 0626T entries shown under ADM1001.032.

MP Criteria (chunk reference)

Chunk refMP Criteria entries consistently state: 'Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.'

Linked policiesExamples include SUR710.022, SUR703.* and other SUR/MED policy IDs listed per code.

Provider actionPredetermination is recommended for codes flagged MP Criteria to reduce denial risk.

EIU (alternate)

Alternate EIU noteEIU: 'Procedure/service not reimbursed by the Plan: Not subject to pre-service review' appears for devices, tests, and specific procedures; check CPCP entry for details.

Examples36474 (endovenous mechnchem add-on), 82523 (collagen crosslinks) noted as EIU.

ActionDo not expect predetermination to render reimbursement for EIU-coded services unless policy is changed.

MP Criteria (alternate)

MP Criteria altWhen MP Criteria is indicated, the provider should submit for Recommended Clinical Review (Predetermination) referencing the named SUR/MED policy to avoid post-service review.

ExamplesA2014–A2018 entries reference SUR704.012 and include MP/EIU/add/retire date notes.

Provider tipConfirm effective/retire dates in the list when submitting predetermination for HCPCS A-codes.

MP Criteria (HCPCS/A-code reference)

HCPCS/A-code referenceA2014–A2018 are listed under SUR704.012 (Bioengineered Skin and Soft Tissue Substitutes) with MP Criteria / EIU annotations and effective/retire dates noted.

Provider actionSubmit predetermination when A-codes reference MP Criteria; check add/retire effective dates in the entry.

ExampleA2014 entry shows 'Add effective 04/01/2023' and 'Retire effective 03/31/2023' variations in the listing.

EIU (HCPCS/A-code reference)

EIU HCPCSSeveral HCPCS C- and A-codes (e.g., C9354, C9356, A2014–A2018) are flagged EIU or not reimbursed by the Plan in the list.

PolicyThese entries reference SUR704.012 or ADM1001.032 as applicable for bioengineered products and EIU designations.

ImplicationBilling these HCPCS items when marked EIU risks denial; verify policy before submission.

OpenPayer

Commercial Benefit Procedure Code List — Plastic/Reconstructive Surgery (coverage mapping of CPT/HCPCS/T codes)

Coverage designations and routing

Procedure and HCPCS code groups

What providers must do

Document purpose and scope

Key terms and designations