Blue Cross Blue Shield NM plastic surgery policy update

Code group coverage designations

Codes are grouped with one of the following designations:

MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review.

Many codes in the list are labeled MP Criteria (see code lines).

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

Some codes are explicitly Non Covered (examples in code list).

EIU: Procedure/service considered experimental, investigational and unproven (EIU); not reimbursed by the Plan.

EIU entries are not reimbursed and reference the EIU/CPCP policy.

Unlisted or undefined procedures may be subject to contract/clinical review and require supporting documentation.

Many '99' unlisted codes appear throughout the table; submit documentation when billing.

Administrative coverage categories

Coverage stance and required actions as indicated per code:

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

Applies to many listed CPT/HCPCS codes; pre-service submission recommended where feasible.

EIU (Excluded): Procedure/service not reimbursed by the Plan; not subject to pre-service review. Check the EIU/CPCP policy for details.

Examples in the table include codes such as 20560, 20561, 20985 and various device/product codes.

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

Specific examples are labeled Non Covered in the code lines (e.g., certain dental and vaccine codes).

Unlisted procedures may be subject to contract/clinical review; submit supporting clinical documentation when requesting review.

Coverage classifications

Codes in this section are assigned one of the following plan designations:

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

Examples include selected vaccine and autopsy codes shown in the table (see specific code lines).

MP Criteria: Services labeled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Multiple diagnostic, surgical and device-related codes are flagged MP Criteria in the listing.

EIU: Services labeled 'EIU' are not reimbursed by the Plan and are governed by the EIU/CPCP policy; they are not subject to pre-service review.

Examples in the excerpt include select laboratory and functional testing codes annotated as EIU.

Coverage designations (MP Criteria vs EIU)

Coverage stance assigned per code entry:

MP Criteria: Codes marked 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Many procedural and device implantation codes in this section are labeled MP Criteria.

EIU (Excluded): Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and not subject to pre-service review; consult the EIU/CPCP policy for guidance.

Multiple therapeutic/diagnostic device and novel procedure codes are annotated EIU in the listing.

Per-code coverage designations (EIU vs MP Criteria)

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

Examples include selected T-codes and device entries flagged EIU in the table.

MP_criteria_review: Codes designated 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' must be reviewed against medical policy criteria; submit for Recommended Clinical Review to avoid post-service review.

Examples include numerous implantation, neurostimulation and other advanced procedure codes.

Code-level coverage determinations

Coverage/status determinations (as stated per code)

Non Covered: Codes explicitly marked 'Non Covered' are not covered by the Plan and not subject to pre-service review (examples include selected dental D-codes and specific durable items).

Refer to individual code lines for exact Non Covered labels (e.g., D7220, D7230, E0210).

EIU / Not Reimbursed: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and not subject to pre-service review; providers should refer to the EIU/CPCP policy.

Examples in the listing include wound warming devices, certain EM/trauma devices and other E-codes marked EIU.

MP Criteria - Clinical Review Recommended: Codes marked 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' should be submitted for Recommended Clinical Review to avoid post-service review.

Some of these codes may also require prior authorization per contract; see code-level notes for details.

Codes in this table are assigned administrative coverage flags. Entries labeled Non Covered or EIU are explicit exclusions from Plan reimbursement: a Non Covered designation means the procedure/service is not covered by the Plan and is not subject to pre‑service review, while EIU (Experimental, Investigational and Unproven) indicates the procedure/service is not reimbursed by the Plan and is likewise not subject to pre‑service review. Examples in this extract include codes marked Non Covered (e.g., 07957) and codes flagged EIU (e.g., 17340).

Specific examples of codes labeled Non Covered are provided in the list. Notably, 21248 and 21249 (reconstruction of the jaw) are shown as Non Covered in the table, and 29440 (addition of walker to cast) is also explicitly designated Non Covered.

Procedures annotated EIU in the table are not reimbursed by the Plan and are not subject to pre‑service review. The document notes many vascular and endovenous procedures and several other CPT/T‑code items as EIU, indicating claims submitted for these codes present a risk of nonpayment because the Plan does not reimburse those services.

A block of dental and periodontal procedure codes (CPT D‑series) is explicitly listed as Non Covered. Examples in this extract include gum and tooth socket procedures (e.g., 41820, 41821, 41870, 41874), each annotated as Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review.

The coding appendix includes many HCPCS/technology items explicitly annotated EIU. The table language for these entries is consistent: EIU: Procedure/service not reimbursed by the Plan. Not subject to pre‑service review. Providers should check the EIU/CPCP policy for additional context when those HCPCS items are encountered.

Where a code carries an explicit EIU annotation the policy states the service is not reimbursed by the Plan and directs the reader to the EIU guidance in the Clinical Payment and Coding Policy (CPCP). This annotation is definitive for claim handling: services marked EIU will not be paid and are not subject to pre‑service review.

Entries marked Non Covered are described with the same consistent wording: Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review. When a code line carries this label the Plan will not reimburse that service; the list includes several categories such as autopsy codes and certain vaccine entries noted as Non Covered.

The document lists many distinct examples across service types that are explicitly marked Non Covered, reinforcing that any code with that label is excluded from reimbursement. These Non Covered entries appear across laboratory, vaccine, dental and other procedural groups in the table.

Note: 29440 (Addition of walker to cast) is explicitly shown in the extract as Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review.

Several additional procedural codes are given as Non Covered examples in the dental and durable medical equipment segments; entries labeled Non Covered are treated as not payable by the Plan and are not subject to pre‑service review.

Other representative Non Covered items appear throughout the list (for example, some transfusion and laboratory items) and the extract consistently uses the same exclusion language: these procedures are not covered and are not subject to pre‑service review.

The table includes an explicit EIU guidance note: codes annotated EIU are not reimbursed by the Plan and the listing refers providers to the EIU/CPCP policy for further details. This cross‑reference signals that EIU labels follow the Plan's experimental/investigational policy framework rather than routine medical‑necessity review.

Multiple codes across HCPCS and CPT sections are shown with Non Covered or EIU flags. The presence of either label in the table indicates an exclusion from payment: Non Covered items are not covered under the Plan, and EIU items are considered investigational/experimental and are not reimbursed.

When the code line includes an EIU note the policy text repeats the exclusion: Procedure/service not reimbursed by the Plan. Not subject to pre‑service review. The extract also shows EIU designation for several durable medical equipment and device codes.

Short form EIU annotations in the HCPCS/E sections carry the same operational effect: items labeled EIU are excluded from reimbursement. The table treats these as plan‑level exclusions rather than items to be handled by pre‑service authorization.

Items marked Non Covered in the table are explicitly excluded from reimbursement and the policy clarifies they are not subject to pre‑service review. Providers billing codes shown as Non Covered should expect the claim to be denied as not covered under the Plan.

Where entries are labeled EIU the document reiterates that these services are not reimbursed by the Plan and refers readers to the EIU guidance within the Clinical Payment and Coding Policy (CPCP) for policy detail and rationale.

The extract contains multiple grouping examples of codes explicitly marked Non Covered across categories (dental, supplies, some D‑codes) and codes marked EIU (certain device, biologic and wound care HCPCS entries). Both designations mean the Plan will not reimburse those services.

Summary: codes flagged EIU are not reimbursed by the Plan; codes flagged Non Covered are explicitly not covered. Both labels are exclusionary and indicate claims submitted under those codes will be at risk for denial.

Where a code line uses language such as “Procedure/service not covered by the Plan” the table is indicating that the item is not a benefit for our members under the Plan; such entries are not subject to pre‑service review and will not be reimbursed.

Representative procedures annotated EIU in this extract include sensory testing and quantitative sensory test codes (for example, 0108T, 0109T, 0110T), and several device/DME codes; the shared annotation in each line signals the same exclusionary payment stance.

The policy treats Non Covered items as not medically necessary for payment under the Plan’s coverage terms: codes labeled Non Covered are presented as services the Plan will not reimburse and are not subject to pre‑service review.

The document shows representative Non Covered examples across categories — dental (D‑codes), supplies (E‑codes) and miscellaneous HCPCS items — reinforcing that when the Non Covered label is present the service is outside Plan benefits and not payable.

Additional Non Covered items appear in the coding tables; each carries the same operational effect: the Plan will not pay for services annotated as Non Covered and these are not subject to pre‑service review.

Codes labeled Non Covered in the extract are treated as not payable—submissions for those codes are expected to be denied or processed as out‑of‑scope for benefits under the Plan.

Restated: entries labeled EIU are considered experimental/investigational and therefore not reimbursed by the Plan. The table consistently pairs that label with a direction to consult the EIU/CPCP policy for further context.

Procedure and HCPCS/CPT Code Lists

HCPCS / CPT / CPT-Add-on / HCPCS (mixed) — Consolidated listmixed

0001A	ADM SARSCOV2 30MCG/0.3ML 1ST — Non Covered; Add effective 04/18/2023
0002A	ADM SARSCOV2 30MCG/0.3ML 2ND — Non Covered; Add effective 04/18/2023
0003A	ADM SARSCOV2 30MCG/0.3ML 3RD — Non Covered; Add effective 04/18/2023
0063U	NEURO AUTISM 32 AMINES ALG — EIU
0066U	PAMG-1 IA CERVICO-VAG FLUID — EIU
0084U	Rbc Dna Gnotyp 10 Bld Groups — Non Covered
0087U	Crd Hrt Trnspl Mrna 1283 Gen — Non Covered; Retire effective 09/01/2023
0089U	Trnsplj Kdn Algrft Rej 1494 — Non Covered; Retire effective 09/01/2023
0091A	ADM SARSCOV2 50 MCG/.5 ML1ST — Non Covered; Add effective 04/18/2023
0092A	ADM SARSCOV2 50 MCG/.5 ML2ND — Non Covered; Add effective 04/18/2023

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Ophthalmology / Vision / Eye — Not CoveredHCPCSNot Covered

92340	Fit Spectacles Monofocal — Non Covered
92341	Fit Spectacles Bifocal — Non Covered
92342	Fit Spectacles Multifocal — Non Covered
92354	Fit Spectacles Single System — Non Covered
92355	Fit Spectacles Compound Lens — Non Covered
92370	Repair & Adjust Spectacles — Non Covered
92499	Unlisted Ophthalmic Service/Procedure — Unlisted

Audiology / Vestibular / ENT — EIU / Non CoveredCPT

92512	Nasal Function Studies — EIU
92517	VEMP Test I&R Cervical — EIU
92518	VEMP Test I&R Ocular — EIU
92519	VEMP Test I&R Cervical&Ocular — EIU
92546	Sinusoidal Rotational Test — MP Criteria
92548	CDP-SOT 6 COND W/I&R — EIU
92549	CDP-SOT 6 COND W/I&R MCT&ADT — EIU

Gastrointestinal / Motility / Diagnostic — MP Criteria / EIUCPT

91110	GI Tracer Imaging Intral Esoph-ile — MP Criteria
91117	Colon Motility 6 Hr Study — MP Criteria
91132	(referenced) Electrogastrography? — EIU noted

Cardiac / Remote Monitoring — MP CriteriaCPT

93228	Remote 30 Day ECG Review/Report — MP Criteria
93229	Remote 30 Day ECG Tech Support — MP Criteria
93660	Tilt Table Evaluation — MP Criteria
93702	BIS Extracellular Fluid Analysis — EIU
93740	Temperature Gradient Studies — EIU
93798	Cardiac Rehab/Monitor — MP Criteria / Non Covered note present
93799	Unlisted Cardiovascular Service/Procedure — Unlisted

Neurology / EEG / Monitoring — Mixed statusesCPT

95700	EEG Continuous Recording with Video EEG Tech — Non Covered / MP Criteria noted
95705	EEG w/o Video 2-12 Hr Unmonitored — Non Covered
95706	EEG w/o Video 2-12Hr Intermittent Monitor — Non Covered
95919	Quant Pupillary Testing — MP Criteria; Add effective 01/01/2023
95999	Unlisted Neurological Diagnostic Procedure — Unlisted
95954	EEG Monitoring/Giving Drugs — MP Criteria
95957	EEG Digital Analysis — MP Criteria

Neuro / Implantable Device Programming and Auditory — MP CriteriaCPT

92640	Auditory Brainstem Implant Programming — MP Criteria
926?	(other auditory programming codes referenced elsewhere)

Pulmonary / Respiratory — EIU / Non CoveredCPT

94014	Patient Recorded Spirometry — EIU
94453	HAST with report — Non Covered
94799	Unlisted Pulmonary Service/Procedure — Non Covered

Physical Medicine / Rehab / Therapy — MP Criteria / EIU / Not CoveredCPT

97533	Sensory Integration — MP Criteria
97537	Community/Work Reintegration — MP Criteria
97610	Low Frequency Non-Thermal Ultrasound — EIU
97799	Unlisted Physical Medicine/Rehab Procedure — Unlisted
99024	Postoperative Follow-Up Visit — Non Covered
99026	In-Hospital On Call Service — Non Covered
99050	Medical Services After Hours — Unlisted/MP Criteria
99056	Medical Service Out of Office — Unlisted/MP Criteria

Speech Generating Device (SGD) / AAC / Communication Devices — MP Criteria / SGD duration bandsHCPCS

E2500	SGD digitized prerecorded message <=8 minutes — MP Criteria
E2502	SGD prerecorded message >8 min <=20 min — MP Criteria
E2504	SGD prerecorded message >20 min <=40 min — MP Criteria
E2508	SGD spelling/physical contact variant — MP Criteria
E2510	SGD with multiple methods/message/accessories — MP Criteria
E2511	SGD software program for PC/PDA — MP Criteria
E2512	SGD accessory mounting system — MP Criteria
E2599	SGD accessory NOC — Unlisted

Durable Medical Equipment / Supplies / Mobility — Mixed statusesHCPCS

A9300	Exercise equipment — Non Covered
A9598	PET DX for non-tumor — Unlisted
A9698	Non-rad contrast material NOC — Unlisted
A9900	Supply/accessory/service — Unlisted
E0616	Cardiac event recorder — MP Criteria
E0677	Non-pneumatic sequential compression trunk — MP Criteria; Add effective 07/01/2023 noted
E0670	Segmental pneumatic appliance full arm — MP Criteria
E0675	Pneumatic compression device — EIU
E1002	Power seat tilt — MP Criteria
E1230	Power operated vehicle — MP Criteria

HCPCS C-codes / Skin substitute / Grafts / Implants — MP Criteria / EIUHCPCS

C1823	Gen neuro trans sen/stim — EIU
C5273	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C5274	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C5275	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C5276	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C5277	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C5278	Low cost skin substitute app — MP Criteria; Add effective 04/01/2023
C9399	Unclassified drugs/biologicals — MP Criteria; prior auth may be required

Dental / Oral / Reproductive storage and related D-codes — Mixed statusesmixed

D7210	Extraction erupted tooth — Non Covered
D7220	Removal impacted tooth - soft tissue — Non Covered
D7230	Impacted tooth - partially bony — Non Covered
D3410	Apicoectomy - anterior — Non Covered
D1705	SARS-COV-2 COVID-19 vaccine (specific) — Non Covered
D1706	SARS-COV-2 COVID-19 vaccine dose 2 — Non Covered
89346	(reproduction storage-related code present in source)
89342	Storage/year embryo(s) — MP Criteria
89343	Storage/year sperm/semen — MP Criteria
89344	Storage/year reproductive tissue — MP Criteria

Pathology / Microbiology / Immunology — EIU / Non Covered / MP CriteriaCPT

90399	Unlisted vaccine or toxoid — Unlisted (present in source list)
86328	IA NFCT AB SARS-COV2 COVID19 — EIU; Add effective 06/01/2023
86408	Neutralizing antibody SARS-COV2 — EIU; Add effective 06/01/2023
86769	SARS-COV-2 COVID-19 Antibody — EIU; Add effective 06/01/2023
91110	(also appears in imaging/gastrointestinal grouping)

Prior Authorization, Clinical Review & Submission Guidance

Denial Risk

Unlisted code review risk

Codes not specifically defined or classified (Unlisted/Undefined) may trigger additional contract or clinical review and could result in claim delays or denials if supporting documentation is not provided. Submit unlisted codes with full clinical documentation and an explanation of the procedure to support medical necessity determinations.

Unlisted/Undefined codes (examples in this section: 15999, 19499, 22899, 32999, 38129, 94799, many '99x' entries) may be subject to contract or clinical review.

Denial Risk

Non Covered codes — denial risk

Some services are explicitly labeled Non Covered by the Plan and are not eligible for reimbursement. These services are not subject to pre-service review; billing them may result in automatic denial under member benefits.

Non Covered examples in this section: dental/orthodontic codes (D7220, D7230, D8210, D8220), certain behavioral or ancillary services (90880, 86910, 86911), and various HCPCS/CPT entries noted as 'Non Covered'.

Denial Risk

EIU (Excluded / Not reimbursed) — denial risk

Codes flagged as EIU (Experimental, Investigational, Unproven) are not reimbursed by the Plan and are not subject to pre-service review. Providers should check the CPCP EIU policy for exceptions. Submitting these services for payment may result in denial.

EIU examples in this section: many CPT/HCPCS entries (e.g., 20560, 20561, 22868–22870, 36473–36474, 43206, A2001–A2008, A2015–A2017, E0487, E0769, etc.).
Check the Clinical Payment and Coding Policy (CPCP) EIU guidance for specifics and any effective-dates noted.

Documentation Required

MP Criteria — recommended clinical review

Procedures/services reviewed against Medical Policy Criteria (MP Criteria) should be submitted for Recommended Clinical Review prior to service when possible. Failure to obtain or submit the Recommended Clinical Review may trigger post-service review and increase the risk of denial if plan medical necessity criteria are not met.

MP Criteria examples: many reconstructive, implant, transplant, and durable medical equipment codes throughout this section (e.g., 15825–15879 series, 19316–19330 series, 38206, 38230, 38241, E0485/E0486, C1833, C2624, etc.).
When MP Criteria applies, submit supporting clinical documentation and consider pre-service submission to avoid post-service review.

Billing Rule

Services marked 'Non Covered' or 'EIU' — billing guidance

Services marked Non Covered or coded as EIU will generally be denied if billed. Before billing, verify member benefits and whether prior authorization or a Recommended Clinical Review is required for related services. For codes that are flagged EIU or Non Covered, do not expect reimbursement unless an explicit exception is documented in member benefits or an applicable policy.

Examples: codes flagged as Non Covered or EIU in this section (see callouts above).
Providers should consult the member benefit booklet or contact customer service for coverage determinations prior to performing services.

Prior Authorization

MP Criteria review may trigger denial without prior review — submit for Recommended Clinical Review

When MP Criteria applies to a procedure or service, submit the MP Criteria codes for Recommended Clinical Review before rendering services whenever feasible. This reduces the risk of retrospective (post-service) denials and supports timely benefit determinations.

Submission recommendation applies to MP Criteria codes throughout the list (examples: tissue augmentation/reconstruction codes, implant-related codes, transplant-related codes).
Provide complete supporting clinical documentation with the request to facilitate review.

Key Definitions and Term Glossary

Definition — MP Criteria

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

ImplicationCodes labeled MP Criteria typically require submission for Recommended Clinical Review; may also require prior authorization per contract

SourceTop-of-document definitions and definitions module entries

Definition — Non Covered

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

ImplicationServices labeled Non Covered are not reimbursable under the Plan and may be denied if billed

Source noteDocument header and multiple code lines (e.g., dental and autopsy codes) label items Non Covered

Definition — EIU (Experimental, Investigational and Unproven)

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

ActionCheck EIU policy (Clinical Payment and Coding Policy) for details when a code is labeled EIU

Source exampleMultiple entries (e.g., 20560, 20985, 86408) are marked EIU in the table

Definition — Unlisted or Undefined

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

Provider guidanceSubmit supporting clinical documentation when billing unlisted codes; they may trigger contract or clinical review

Source examplesMany codes ending in '99' throughout the list are labeled Unlisted

Definition — MP Criteria (alternate chunk refs)

MP Criteria (alternate ref)MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review.

NoteReferenced across multiple code groups as the action required for MP Criteria codes

Definition — Unlisted/Undefined (alternate chunk refs)

Unlisted/Undefined (alternate refs)Unlisted or Undefined: Procedures/services not specifically defined or classified; may be subject to contract/clinical review.

ExamplesEntries such as 20999, 87797, 87999 are shown as Unlisted in the table

Definition — EIU (alternate chunk refs)

EIU (alternate refs)EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy (CPCP).

Examples86408/86409/86413/86769 and many other lab/immunology codes marked EIU

Definition — MP Criteria (alternate chunk refs)

MP Criteria (alternate refs 2)MP Criteria: Procedure/service reviewed against Medical Policy Criteria; submit for recommended clinical review to avoid post-service review.

ContextUsed for device/implant and many procedural codes (e.g., 69930, 69728) with date annotations

Definition — EIU (alternate chunk refs)

EIU (alternate refs 2)EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review; consult EIU/CPCP.

Examples82523, 83695, 83698, 83701 and others flagged EIU in the lab/chemistry sections

Definition — Unlisted (alternate chunk refs)

Unlisted (alternate refs 2)Unlisted: Procedure/service not specifically defined or classified; may be subject to contract/clinical review.

Examples88099 (unlisted necropsy), 91299, 86999 and other '99' codes shown as Unlisted

Definition — EIU (single-chunk ref)

EIU (single-chunk ref)EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy (CPCP).

UsageAppears in per-code annotations (e.g., 95919 date note alongside EIU guidance elsewhere)

Definition — MP Criteria (single-chunk ref)

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

Provider actionRecommended Clinical Review submission is advised for MP Criteria codes to avoid post-service review

Definition — MP Criteria (alternate chunk refs)

MP Criteria (alternate refs 3)MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review.

NoteReiterated in multiple mid-list code group entries

Definition — EIU (alternate chunk refs)

EIU (alternate refs 3)EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy within Clinical Payment and Coding Policy (CPCP).

Examples91133, 86328 and other diagnostic/immunology codes show EIU with Add effective dates in the table

Definition — Unlisted (alternate chunk refs)

Unlisted (alternate refs 3)Unlisted: Procedure/service not specifically defined or classified; may be subject to contract/clinical review.

Practical noteUnlisted codes often require submission of supporting documentation and may be subject to contract review

OpenPayer

Plastic and reconstructive surgery procedure code listing and review requirements

Coverage Criteria and Designations

Procedure and HCPCS/CPT Code Lists

Prior Authorization, Clinical Review & Submission Guidance

Document Background and Scope

Key Definitions and Term Glossary