CurrentBlue Cross Blue Shield - New MexicoPolicy SUR716.001

Utilization management for outpatient cosmetic and reconstructive CPT procedures

Lists CPT procedure codes and the utilization management requirements (pre-operative evaluation, H&P, operative report, photographs when applicable) that govern prior authorization and medical record documentation for outpatient cosmetic and reconstructive surgeries for Blue Cross Blue Shield New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyUtilization management for outpatient cosmetic and reconstructive CPT procedures

Policy CodePolicy SUR716.001

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit required documentation (pre-operative evaluation, history & physical including functional impairment, and operative report) with prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+CPT entries shown

H&P + operative reportCommon records required

LMNRoutine doc requested

BCBSNMPolicy source

Coverage Criteria and Documentation Requirements

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inv-01: Documentation criteria — Documentation required for listed CPT codes

Documentation required for listed CPT codes

Medical record elements: Pre-operative evaluation, history and physical including documentation of functional impairment, and operative report must be provided

For eyelid revision CPTs (e.g., 15820/15821) include photographs of the affected eyes.

inv-02: General documentation requirement — Coverage and documentation linkage

Coverage and documentation linkage

Documentation required for review: Pre-operative evaluation, history and physical including documentation of functional impairment, and operative report are required for medical review of listed CPT codes; some codes additionally require items such as pathology reports, height/weight, prior conservative treatment, medication records, patient age, duration of condition, or grams of tissue removed.

Refer to the BCBSNM medical policy(s) listed per CPT for full medical necessity criteria.

inv-03: Coverage determination depends on submitted documentation and referenced BCBSNM DME policies

Coverage determination depends on submitted documentation and referenced BCBSNM DME policies

Documentation required: Claims for listed HCPCS/DME codes require the specific documentation indicated for each code (for example: Letter of Medical Necessity or history and physical stating diagnosis, functional limitations, duration, anticipated length of need, and device-specific justification).

See the BCBSNM DME policy referenced for each HCPCS (e.g., DME101.034, MED202.060, DME101.010) for detailed clinical criteria.

inv-04: Documentation-dependent coverage — Coverage and review are dependent on submission of required documentation and applicable policy cross-references

Documentation-dependent coverage — Coverage and review are dependent on submission of required documentation and applicable policy cross-references

Documentation required for DME and device codes: Provide history and physical or clinical notes describing diagnosis; abilities and limitations as they relate to the equipment; frequency and nature of activities performed; duration of the medical condition; anticipated length of use; and a Letter of Medical Necessity when specified.

This requirement is supported across multiple DME/wheelchair entries (see E1235/E1236 and related codes).

Not a covered benefit (example): E1310 (whirlpool, nonportable built-in type) is designated 'Not a covered benefit' and is not eligible for coverage under the listed policies.

E1310 explicitly listed as Not a covered benefit in the DME entries.

inv-05: Policy-referenced medical necessity — Coverage and medical necessity governed by referenced BCBSNM medical policy entries and New Mexico Administrative Code / MCG where indicated

Policy-referenced medical necessity — Coverage and medical necessity governed by referenced BCBSNM medical policy entries and New Mexico Administrative Code / MCG where indicated

policy-referenced criteria: Providers must follow the specific BCBSNM medical policy and the clinical criteria hierarchy (e.g., New Mexico Administrative Code, MCG) referenced for each code when establishing medical necessity for the service.

See the Medical Policy Number(s) listed with each code for the applicable BCBSNM policy.

inv-06: Medical necessity determination (referenced) — Coverage and medical necessity determinations follow the referenced clinical criteria hierarchy

Medical necessity determination (referenced) — Coverage and medical necessity determinations follow the referenced clinical criteria hierarchy

Referenced evaluation process: Medical necessity for the listed L-codes and related prosthetic/DME items is determined using the New Mexico Administrative Code and MCG clinical criteria hierarchy; supporting documentation (for example a Letter of Medical Necessity with anticipated length of need, functional status, and description of the condition) must be submitted.

Exact clinical rules are contained in the DME104.012 and related BCBSNM policies referenced per L-code.

inv-07: Coverage condition — Coverage is subject to submission of required documentation and the referenced clinical criteria hierarchy (New Mexico Administrative Code / MCG)

Coverage condition — Coverage is subject to submission of required documentation and the referenced clinical criteria hierarchy (New Mexico Administrative Code / MCG)

Documentation required: Prior authorization or medical records request must include a Letter of Medical Necessity (length of time equipment is needed, functional status if applicable, and description of medical condition). For specified powered/complex devices and facial/upper‑limb prostheses, include history and physical and a functional status evaluation from a physiatrist or physical therapist when indicated.

Providers must follow the clinical criteria hierarchy referenced in the policy entries (e.g., DME104.012, DME104.001).

inv-08: Coverage conditioned on submission of specified documentation and adherence to referenced BCBSNM policy

Coverage conditioned on submission of specified documentation and adherence to referenced BCBSNM policy

Documentation and policy mapping: Provider must submit the required clinical documentation (history and physical, letter of medical necessity, functional status evaluation or plan of care as specified) and the service will be reviewed against the BCBSNM medical policy mapped to that HCPCS/CPT code.

Referenced policies (for example DME104.001, SUR712.033, SUR704.012) contain the detailed medical necessity criteria and prior authorization instructions.

inv-09: Coverage criteria by service type — Services are subject to medical necessity review and require submission of specified documentation and sometimes BCBSNM medical policy criteria

Coverage criteria by service type — Services are subject to medical necessity review and require submission of specified documentation and sometimes BCBSNM medical policy criteria

General documentation: Submit recent history and physical, plan of care, and documentation of medical necessity when required for the code (for example S9473, T5999, and many DME/prosthetic entries).

See individual code entries for exact document list and policy mapping.

LTSS-specific: For LTSS/home- and community-based service codes (e.g., T1002, T1003, T1019, T2031, T2038) include NFLOC documentation and plan of care as indicated.

NFLOC criteria and instructions are per NMAC/Managed Care Policy Manual referenced with the LTSS codes.

Behavioral health prior auth: Partial hospitalization (S0201), respite (T1005), and Applied Behavioral Analysis services (97153, 0373T) require prior authorization beyond defined day/session limits and submission of behavioral health level-of-care evidence or the ABA Stage 3 form as specified.

The codes listed in this document are an index of procedure and supply codes used for utilization management. The presence of any code on this list does not by itself guarantee coverage under a member’s benefits contract. Member benefits vary; providers should consult the member’s benefit booklet or contact customer service to confirm whether a specific service or supply is covered for that member. The source also notes that green-highlighted codes are managed by Carelon (formerly AIM), which affects the review pathway for some items.

This extract does not enumerate procedural exclusions within the list itself. Instead, coverage determinations and any exclusions are governed by the BCBSNM medical policies referenced alongside individual codes (for example, SUR716.001, SUR717.001 and the DME policy pages). Providers must review the mapped BCBSNM medical policy for each code to determine if an exclusion applies.

The HCPCS entry E1310 (Whirlpool, nonportable built-in type) is explicitly designated as "Not a covered benefit." Claims for this specific code should be treated as non-covered per the document.

The document flags devices that are not coded by DME PDAC or that do not meet PDAC criteria (for example, K0899 — "Power mobility device, not coded by DME PDAC or does not meet criteria"). For DME and power-mobility entries the medical records request typically requires a history and physical or clinical notes including the anticipated length of use, and for other prosthetic/DME items a Letter of Medical Necessity describing duration of need and functional status is requested as specified by the mapped BCBSNM policy.

Provider Steps: Prior Authorization, Submission & Documentation

Prior Authorization

Prior authorization may be required

Prior authorization may be required for many listed procedures. Verify member benefits and the applicable BCBSNM or delegated vendor medical policy (MCG/Carelon) before scheduling services. Presence on this list does not guarantee coverage — consult the member benefit booklet and mapped medical policy.

Check BCBSNM medical policy site: https://medicalpolicy.bcbsnm.com/
Carelon prior auth/records portal: https://providerportal.com/ or 1-800-859-5299

Prior Authorization

Transplant prior authorization / documentation

Transplant CPTs require transplant approval on file or submission of transplant evaluation and plan. If transplant approval is already on record, include the date of transplant with the claim; if not, submit H&P, transplant evaluation, and the expected or actual transplant date.

Applicable codes include lung (32851–32853), hematopoietic cell/stem cell (38208,38209,38240–38241), kidney/pancreas (50360,50365,50380,48554) and others mapped to SUR703.* policies.
If approval not on record: submit history & physical, transplant evaluation, and transplant date.

Prior Authorization

Prior authorization required for selected radiology and radiation therapy codes

Selected radiology and radiation therapy codes require prior authorization or delegated review. For advanced imaging and specialty radiology codes routed to Carelon, submit requests and supporting records through Carelon. Proton beam and certain radiation therapy CPTs require history & physical and documentation of medical necessity.

Carelon-governed imaging examples: 77046–77049 (breast MRI), 0648T–0649T, A9602, A9800.
Proton therapy examples: 77520,77522–77525 — submit H&P and documentation of medical necessity.

Prior Authorization

Carelon-referenced codes — records submission

Carelon-referenced codes must be submitted via the Carelon portal or phone number. Include all requested clinical documentation per Carelon guidance (history & physical, relevant prior imaging/reports, and clinical indication) to avoid delays.

Portal: https://providerportal.com/ or 1-800-859-5299
Examples: 77046–77049, 0648T–0649T, A9602, A9800

Documentation Required

DME, hospital beds and lift codes — documentation required

Durable medical equipment (DME), hospital bed and patient lift codes require specific documentation (history & physical, plan of care, Letter of Medical Necessity) describing diagnosis, functional status, duration and anticipated length of use.

Powered air mattress E0277: LMN with anticipated length of use and mobility status.
Hospital beds E0303/E0465: H&P or clinical notes and anticipated length of use.
Lifts E0630/E0635/E0637/E0638: LMN describing condition and mobility status.

Documentation Required

Prior authorization / medical records required — standard documentation and denial risk

Prior authorization or submission of medical records is required for many services; typical required documents include a recent history & physical, operative report (if applicable), plan of care, and Letter of Medical Necessity. Insufficient clinical detail or missing documentation may lead to denial or delayed authorization.

Standard requested records: recent H&P, pre-operative evaluation, operative report, plan of care, functional status evaluation, and LMN when specified.
Missing items commonly leading to denial: H&P, functional status, operative report, proof of prior authorization/approval.

Note

Coverage contingent on member benefits and medical policy

Coverage is contingent on member benefits and mapped medical policies. Codes listed are cross-referenced to BCBSNM or delegated medical policies (MCG/Carelon); always confirm eligibility, benefits, and any policy-specific criteria before providing services.

Consult member benefit booklet in addition to medical policy mapping.
Codes may be subject to clinical criteria hierarchy (NMAC, MCG, BCBSNM medical policy, Carelon).

Denial Risk

Missing documentation risk — submit complete records

Missing or incomplete documentation increases the risk of denial. Submit complete H&P, documentation of medical necessity, operative reports, functional status evaluations, LMNs, anticipated length of use for DME, and any vendor-specific forms to reduce denials.

Examples of consequences: denial for E1310 (not covered) or for DME claims lacking LMN/H&P.
If records are incomplete, prior auth may be denied or claim payment delayed.

Documentation Required

Documentation required for enteral formula and parenteral nutrition

Enteral and parenteral nutrition codes map to the BCBSNM Nutritional Support policy (MED201.011). For enteral formulas (B41xx), submit history & physical or clinical notes including anticipated length of use. For parenteral nutrition, higher-protein preparations (e.g., B4199/B4189/B4193) require recent H&P, plan of care, and documentation of medical necessity.

Enteral: B4102–B4104 — H&P or clinical notes and anticipated length of use.
Parenteral: B4189 (10–51 g) and B4193 (52–73 g) — H&P, plan of care, documentation of medical necessity.

Documentation Required

Prosthetics, powered devices and facial prostheses — LMN and clinical documentation required

Prosthetic and orthotic items require a Letter of Medical Necessity plus clinical documentation (history & physical, functional status eval, description of condition). Powered devices and facial prostheses often require additional documentation from a physiatrist or physical therapist describing functional needs.

Lower-limb prosthetics (L5xxx series): LMN including length of time equipment needed and functional status.
Upper-limb and facial prostheses (L7045, L8040–L8046): H&P, LMN, and functional status evaluation from a physiatrist or PT when requested.
Powered wheelchair components (E2300/E2301, K0850–K0899): comprehensive H&P describing diagnosis, abilities/limitations, duration, and anticipated length of use.

Definitions and Reference Terms

inv-181: Managed-by indicator — Carelon-managed codes

Managed-by indicator meaningGreen highlighted codes are managed by Carelon (formerly AIM)

Carelon contact for records submissionCarelon provider portal or phone number listed for advanced imaging records submission (e.g., 0648T entries)

ImplicationCodes highlighted green should be submitted via Carelon per the entry instructions

inv-182: Required documentation (general)

Core required documentsPre-operative evaluation, history and physical including functional impairment, and operative report are required for many CPT entries

Additional common itemsWhere specified, include pathology reports, height/weight, prior conservative treatment, and photographs (e.g., eyelid revisions)

Policy cross-referenceEach code line lists the BCBSNM medical policy to reference for full medical necessity criteria

inv-183: Additional documentation (procedure-specific)

Procedure-specific additionsSome codes require specific items such as number of grams of tissue removed (e.g., 19318), transplant approval date or transplant evaluation (e.g., 38208), or NFLOC for LTSS codes (e.g., S9473/T1002)

Functional status evaluationsFor certain prosthetics and powered devices, a functional status evaluation from a physiatrist or physical therapist may be requested

Forms and evidenceABA codes require submission of the Applied Behavioral Analysis Stage 3 Form for New Mexico Centennial requests

inv-184: Clinical Criteria Hierarchy — NMAC, MCG, BCBSNM

Hierarchy orderNew Mexico Administrative Code, MCG, then BCBSNM Medical Policy form the clinical criteria hierarchy referenced in the document

UseProviders should follow the referenced hierarchy when preparing submissions and to evaluate medical necessity criteria

Policy linkageEach code entry cites its Clinical Criteria Hierarchy and mapped BCBSNM Medical Policy number where applicable

inv-186: Carelon — utilization management vendor

Carelon roleCarelon is referenced as the utilization management/clinical review vendor and the portal for records submission for many radiology and advanced imaging codes

When usedCarelon is listed as the Clinical Criteria Hierarchy source for certain codes (e.g., 0648T, A9602) and as contact for records submission

Former nameCarelon was formerly known as AIM

inv-187: Letter of Medical Necessity definition and use

DefinitionLetter of Medical Necessity (LMN): provider-authored document describing anticipated length of use, functional status if applicable, condition being treated, and plan of care to justify DME/prosthetic coverage

When requiredRequested for many E-codes, L-codes, Q-codes and prosthetic items (see individual code entries) as part of medical records for PA/review

Typical contentsLength of time equipment needed, description of medical condition, functional abilities/limitations, and device-specific justification

inv-191: NFLOC — Nursing Facility Level of Care

NFLOC termNFLOC = Nursing Facility Level of Care

Context of useReferenced for LTSS and certain home- and community-based services where NFLOC documentation and criteria apply (e.g., G9006, G9012)

Submission requirementInclude NFLOC documentation with recent H&P, plan of care and documentation of medical necessity when listed

inv-197: NFLOC criteria used for LTSS and certain home- and community-based services in New Mexico

Use of NFLOC criteriaNFLOC criteria are used to evaluate LTSS services and certain home/community-based services in New Mexico (entries reference NMAC and Centennial Care BH LOC guidelines)

ExamplesCodes referencing NFLOC include G9006, G9012, and LTSS-related T-codes which require recent H&P, plan of care, and NFLOC documentation

Provider actionWhen NFLOC is listed, include NFLOC evidence and complete required forms per the referenced NMAC instructions

E0641	STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR
E0642	PEDIATRIC, WITH OR STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure
E0652	PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE
E0660	Non-segmental pneumatic appliance for use with pneumatic compressor, full leg
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg
E0667	Segmental pneumatic appliance for use with pneumatic compressor, full leg
E0668	Segmental pneumatic appliance for use with pneumatic compressor, full arm
E0669	Segmental pneumatic appliance for use with pneumatic compressor, half leg

OpenPayer

Utilization management for outpatient cosmetic and reconstructive CPT procedures

Coverage Criteria and Documentation Requirements

Listed CPT/HCPCS Codes and Code Details

Provider Steps: Prior Authorization, Submission & Documentation

Policy Background and Scope

Definitions and Reference Terms

Policy Revision History