CurrentBlue Cross Blue Shield - New MexicoPolicy SUR716.001 SUR716.011

Cosmetic and Reconstructive Procedures (Reconstructive Breast Surgery and related CPT code list)

This document lists CPT codes and associated administrative requirements for cosmetic and reconstructive procedures (including reconstructive breast surgery and related services) as managed by BCBSNM; it is intended for providers submitting claims and prior authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCosmetic and Reconstructive Procedures (Reconstructive Breast Surgery and related CPT code list)

Policy CodePolicy SUR716.001 SUR716.011

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a history and physical, documentation of medical necessity, and the operative report with prior authorization or claims as specified for listed CPT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+CPT codes listed in this extract

Green highlighted codesmanaged by Carelon (AIM)

Removed 1/1/2023Some implant/prosthesis CPT entries note removal

H&PDocumentation frequently required

Updated 5/01/2023

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

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Coverage mapping and administrative criteria

Codes are listed with associated documentation requirements and internal policy references

Documentation required: For the listed CPT codes, providers must submit a history and physical, documentation of medical necessity, and the operative report as part of claims or prior authorization submissions.

Repeated across multiple code entries (see chunks 126 and 145).

Carelon / Vendor / Policy cross-reference: Some CPT codes reference BCBSNM internal policies (e.g., SUR717.001) or external management/vendor routing for prior authorization; follow the referenced policy or Carelon provider portal/phone for authorization and submission instructions.

See code-specific lines for SUR717.001 and other cross-references (chunks 126, 145).

Removed / historical code notes: Certain CPT entries may be marked as removed or have effective dates noted in the code list; providers should verify code status and billing eligibility (e.g., entries show 'Added prior to 9/1/2019').

Refer to the code listing for removal/added metadata (chunks 126, 145).

The presence of CPT codes in this listing does not by itself guarantee coverage under a member's benefits. Coverage is determined by the member's specific benefit plan; providers should consult the member benefit booklet or contact customer service to confirm coverage for any service or supply. Green-highlighted codes in the source are managed by Carelon and may follow external management processes.

Several breast implant/prosthesis CPT entries in the table include administrative notes indicating they were removed from this listing. Specifically, CPT codes 19330, 19340, and 19342 are annotated as Removed effective 1/1/2023 in the source and therefore are no longer present in this policy's CPT listing.

The musculoskeletal mapping shows CPT 27280 annotated with a removal note: it is documented as Removed 10/1/2022 in the source excerpt.

The transplant/radiation section lists CPT 36470 with administrative metadata indicating it was Removed effective 1/1/2023 in this table excerpt.

The source includes several unlisted procedure codes (for example, 41899, 43499, 43999) with addition/removal dates and routing instructions. These entries require submission via the Carelon provider portal or phone as indicated; missing the required channel or documentation may affect processing or trigger referral to Carelon.

CPT 56810 is shown in the table with an administrative annotation indicating it was Removed effective 1/1/2023.

The entry for CPT 58720 includes a note that it was Removed effective 1/1/2023; the line also specifies expected documentation (history & physical, documentation of medical necessity, operative report) where applicable.

The table repeatedly pairs many CPT codes with required supporting records. Typical administrative documentation requested includes a pre-operative evaluation, history & physical (including functional impairment), documentation of medical necessity, and the operative/procedure report. For certain codes (e.g., transplant-related or select eyelid procedures) additional items such as transplant evaluation, date of transplant, or a letter of medical necessity are specified.

The excerpt maps eyelid and blepharoplasty CPTs to administrative guidance rather than providing full medical necessity criteria. For several eyelid repair entries (for example, 67908 and related codes) the source references a letter of medical necessity and pairs each CPT with Carelon contact information for management guidance; explicit clinical medical-necessity rules for blepharoplasty/eyelid repair are not stated in these chunks.

Within the provided excerpt there are no standalone coverage criteria or explicit clinical exclusions detailed; the content primarily lists CPT descriptors, administrative notes (including addition/removal dates), and routing/contact instructions to Carelon for prior authorization or guideline lookup. Providers should reference the member's benefit plan and use the Carelon portal or phone for specific authorization and coverage guidance.

CPT and procedure code mappings

Required documentation — Pre-op evaluation, H&P, operative report

Required medical record elementsPre-operative evaluation, history and physical including documentation of functional impairment, and operative report are required to support medical necessity for the listed CPT codes.

Transplant-specific requirementFor transplant-related CPTs, if transplant approval is on record submit the date of transplant; if not, submit history and physical, transplant evaluation, and date of transplant (or equivalent transplant documentation).

Eyelid/selected proceduresSome eyelid or implant procedures may also require photographs or a letter of medical necessity in addition to H&P and operative report as specified per code.

Prior authorization, documentation & submission guidance

Prior Authorization

Carelon prior authorization required

Prior authorization is required through Carelon (formerly AIM) for many listed procedures — providers must use the Carelon provider portal (https://providerportal.com/) or phone (1-800-859-5299 or 1-800-859-5300 where shown) to request prior authorization and determine specific routing and requirements.

Each listed CPT code is paired with Carelon contact information and a Carelon guidelines URL; verify prior authorization requirement separately for each CPT.
Carelon contact: https://providerportal.com/ or 1-800-859-5299 (some entries reference 1-800-859-5300).
For many radiation therapy, musculoskeletal, spine, and radiology CPTs the record explicitly indicates Carelon management — consult Carelon prior to performing or billing these services.
Claims or unlisted procedures routed to Carelon may be denied without prior submission via the Carelon portal — follow Carelon submission channel instructions for unlisted codes (e.g., 41899, 43499, 64999).

Note

CPT code list — verify prior auth separately

Policy background and scope

This document extract covers administrative and code-level mappings for cosmetic and reconstructive procedures, including reconstructive breast surgery, scar revision, dermabrasion, chemical peels, blepharoplasty, and excision of excess skin. It emphasizes that coverage depends on the member's contract, that many CPT entries require supporting documentation, and that certain codes are managed or routed to Carelon for prior authorization or guideline review.

Key terms and documentation definitions

Pre-operative evaluation, history and physical including functional impairment

Elements requestedPre-operative evaluation, history and physical including functional impairment, and operative report are repeatedly requested in the medical record for listed CPT codes (examples: 11920, 11921, 11970).

Policy cross-referenceEntries reference BCBSNM medical policies SUR716.001 and SUR716.011 as the clinical criteria hierarchy for these requests.

Administrative useThese documentation elements are used to support medical necessity determinations and prior authorization/claims processing.

Pre-operative evaluation, H&P including functional impairment and operative report

Standard documentation per codeNasal reconstruction/revision CPT entries (e.g., 30410–30435, 30460–30520) list pre-operative evaluation, history and physical including functional impairment, and operative report as required documentation.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCosmetic and Reconstructive Procedures (Reconstructive Breast Surgery and related CPT code list)

Policy CodePolicy SUR716.001 SUR716.011

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a history and physical, documentation of medical necessity, and the operative report with prior authorization or claims as specified for listed CPT codes.

SourceLink

On This Page

Removed codes (effective 4/1/2023)CPT codes 63194, 63196, 63198 are marked 'Removed 4/1/2023'.

ContextThese entries indicate the codes were removed from the listing on 4/1/2023 per the source table.

Carelon references remainPrior to removal these codes included Carelon routing and guideline links like other spinal procedure entries.

No numeric thresholds in this section

Numeric thresholdsNo numeric thresholds are specified in this section of the document.

Documentation-driven requirementsGuidance in this section centers on required documentation and administrative routing (e.g., Carelon), not numeric cutoffs.

Implication for providersSubmit H&P, documentation of medical necessity, and operative report where requested; do not expect measurable numeric thresholds here.

For CPTs that are not explicitly managed by Carelon in this excerpt, verify prior authorization separately — presence on this list is informational and does not guarantee coverage.

This code list is not exhaustive and presence on the list does not necessarily indicate coverage under the member benefits contract; coverage depends on the member contract — consult the member benefit booklet or customer service.
When a CPT entry lacks an explicit prior authorization trigger in this excerpt, do not assume authorization is not required; check member benefits and Carelon if applicable.

Documentation Required

Pre-operative documentation referenced

Pre-operative documentation is required for many surgical and reconstructive CPTs. Failure to submit required documentation may result in denial or additional review.

Common required items: pre-operative evaluation, history & physical (including functional impairment where specified), operative report, photographs when noted, pathology or medication records as applicable.
Eyelid/brow and related repair codes often require a letter of medical necessity describing the condition being treated (e.g., 67901–67904, 67908).
For hysterectomy and many gynecologic surgery codes submit H&P, documentation of medical necessity, and operative report.
For penile, scrotal, and related prosthesis procedures submit history/physical, documentation of medical necessity, and operative report.

Documentation Required

Transplant prior approval/documentation

Transplant-related CPTs require transplant approval or supporting documentation; if transplant approval is on file submit the approval date, otherwise submit history & physical, transplant evaluation and operative/procedure report.

If transplant approval on record: include date of transplant on submission.
If no transplant approval: submit history and physical, transplant evaluation, and date of transplant where applicable.
Examples: lung, liver, kidney and multivisceral transplant CPTs (e.g., 32851, 32852, 33935, 33945, 44132, 47399, 50360, 50365, 50380).

Prior Authorization

Carelon routing for unlisted procedures / Submission channel for unlisted procedure codes

For unlisted procedure codes and certain miscellaneous CPTs, submit detailed documentation through the specified channel (often Carelon) to describe the services; lack of appropriate submission may trigger denial.

Unlisted codes (e.g., 41899, 43499, 43999, 44132, 47399, 64999) — submit history & physical and operative/procedure report and use Carelon portal/phone when the entry specifies Carelon.
64999: submit documentation to describe the services including history & physical with operative or procedure report.
Follow Carelon routing for unlisted or radiology-related unlisted procedures to avoid administrative denials.

Note

Carelon prior authorization/contact / Administrative contact and specialty mapping

Administrative contact and specialty mapping: many entries include Carelon routing plus a Carelon guidelines link; use these resources for benefit inquiries, specialty-specific rules, and operational guidance.

Carelon guidelines: https://guidelines.carelonmedicalbenefitsmanagement.com/ — consult for detailed clinical criteria.
Carelon portal: https://providerportal.com/ and phone 1-800-859-5299 (some CPTs reference 1-800-859-5300).
Green-highlighted/managed codes denote Carelon management (per source note).

Prior Authorization

Carelon prior authorization required for listed radiology and radiation CPTs

Radiology and radiation therapy CPTs in this excerpt frequently require prior authorization via Carelon; confirm requirements and follow Carelon submission processes.

Examples include brachytherapy, stereotactic radiosurgery, radiation treatment delivery and many CT/MRI/CT-angiography codes listed with Carelon — verify each CPT with Carelon.
When Carelon is listed next to a radiology CPT, use the Carelon portal/phone to request authorization and to access the applicable guideline.
Do not proceed without confirming authorization where Carelon routing is indicated to avoid potential denial.

Documentation Required

Documentation & routing notes for gynecologic surgery codes

Documentation & routing notes for gynecologic and related surgery codes: many hysterectomy and gynecologic CPTs require H&P, medical necessity documentation, and operative report; select gynecologic procedures are routed to Carelon for radiation/brachytherapy services.

Hysterectomy codes (58180, 58240, 58260, 58541, 58552–58553) — submit history & physical, documentation of medical necessity, and operative report.
Brachytherapy or radiation-related gynecologic entries (e.g., 58346) reference Carelon — use Carelon portal/phone and guidelines link for prior authorization and criteria.
Failure to submit required documentation for gynecologic procedures may lead to non-payment or additional review.

Note

No explicit denial triggers or authorization rules stated in this excerpt

Some entries in this excerpt contain no explicit denial triggers or authorization rules; absence of a rule here does not mean none exist — check member contract or Carelon as applicable.

Where the excerpt shows only code listings with Carelon/contact info but no explicit documentation instructions, providers should confirm requirements with Carelon or the member's benefit booklet.
Preserve caution: 'None explicitly stated in this segment' should prompt verification rather than assumption of coverage or lack of need for authorization.

Note

Coverage depends on member contract

Coverage depends on the member contract — inclusion on this list is not a guarantee of coverage; always verify benefits prior to scheduling or performing services.

Consult the member benefit booklet or customer service to determine coverage for a specific member.
Presence on this list is informational; member contracts differ in covered services.

Billing Rule

Provider action checklist

Provider action summary: when Carelon is listed for a CPT use the Carelon portal/phone and guidelines link; for transplant and unlisted codes submit the specified documentation; where documentation requirements are listed, include them with claims to reduce denial risk.

Use Carelon portal (https://providerportal.com/) or phone (1-800-859-5299 or 1-800-859-5300 where shown) for prior authorization and guideline access.
Include pre-operative evaluation, H&P including functional impairment, operative report, letters of medical necessity, pathology, medication records, and transplant evaluation as required per CPT.
Verify each CPT individually — do not assume authorizations or documentation requirements are uniform across codes.

Related policy mappingThese CPT lines reference SUR717.001 and SUR706.001 as policy cross-references for nasal/sinus procedures.

Provider actionInclude H&P and operative report when submitting prior authorization or claims for these procedures.

Add-on code

Definition'ADD-ON' codes denote additional procedure components that supplement a primary service code (examples: 20938, 20939, 20974, 20975).

Carelon routingAdd-on code entries often include Carelon provider portal contact and guideline links for management.

Use in billingReport add-on codes only in conjunction with the appropriate primary procedure code per coding guidelines.

CPT procedure label

Short procedure labelsCode table entries include concise procedure labels used for mapping (e.g., 'INSERT SPINE FIXATION DEVICE' for 22840–22842).

PurposeThese labels provide quick mapping descriptors for administrative and prior authorization workflows.

Carelon linkageMany labeled entries are paired with Carelon contact information and guideline links.

CPT code descriptor

Code descriptor examplesEntries show short descriptors following each CPT code (e.g., 'INJECT SACROILIAC JOINT', 'TOTAL HIP ARTHROPLASTY') used as mapping text in the code list.

FunctionThese descriptors summarize the billed procedure to assist reviewers and routing to appropriate management.

Carelon referencesDescriptors are frequently accompanied by Carelon portal/phone contacts for authorization guidance.

Reconstruction of nose / Revision of nose

Code groupNasal reconstruction/revision CPT group includes 30410–30435 and 30460–30520 and requires pre-op evaluation, H&P including functional impairment, and the operative report.

Policy linkageThese lines reference SUR717.001 and SUR706.001 for related policy guidance.

Provider submissionInclude the specified documentation when requesting prior authorization or submitting claims for nasal reconstruction/revision.

Transplant approval on record

When prior approval existsIf transplant approval is on record, submit the date of transplant with the claim or authorization (applies to listed transplant CPTs).

If no approval on recordIf transplant approval is not on record, provide history and physical, transplant evaluation, and date of transplant (or equivalent documentation) as part of prior authorization.

ExamplesTransplant-related entries include CPTs such as 32851, 33945 and unlisted liver/kidney transplant entries that specify these documentation expectations.

Construct/constructing vagina

Construct/constructing vagina codesCPTs describing construction or revision of a vagina include codes such as 57291, 57295, 57296; entries require submission of history & physical, documentation of medical necessity, and operative report.

Policy cross-referenceThese procedures are linked to SUR717.001 for gender assignment/reassignment surgery guidance.

Provider submission noteInclude H&P and operative report when requesting prior authorization or filing claims for vaginal construction/revision services.

Total hysterectomy (CPT group)

Total hysterectomy groupCPT group for total hysterectomy includes codes such as 58180 and related entries; submissions must include history & physical, documentation of medical necessity, and operative report.

ExamplesEntries list 58180, 58240, 58260, 58262, 58290 with the same documentation expectations.

RoutingSome hysterectomy entries reference SUR717.001 or MCG for routing and clinical criteria guidance.

Laparoscopic-assisted vaginal hysterectomy (LAVH/TLH group)

LAVH/TLH group codesLaparoscopic-assisted vaginal and total laparoscopic hysterectomy codes include 58552–58554 and 58570–58573; submissions require history & physical, documentation of medical necessity, and operative report.

Weight-based distinctionsSome TLH entries note uterus weight distinctions (e.g., uterus >250 g) which are documented in the code descriptions.

Policy cross-referenceThese entries reference SUR717.001 for related surgical policy mapping.

Add-on codes

Add-on annotationSeveral CPT entries are annotated as 'add-on' indicating they supplement primary procedure codes (examples include multiple spine bone graft/add-on codes and spinal disk surgery add-on 63035).

Carelon linkageAdd-on entries frequently include Carelon routing and guideline links for administrative review.

Billing considerationAdd-on codes must be billed in conjunction with the associated primary procedure per coding rules.

Removed codes

Examples of removed codesCertain CPT entries are shown as removed with dates (e.g., 63194, 63196, 63198 marked 'Removed 4/1/2023').

ImpactRemoval indicates the codes were deleted from the listing as of the stated date and may not be billable under this listing after that date.

Provider actionVerify current code sets and payer guidance before billing removed codes.

Unlisted procedure (64999)

Unlisted procedure (64999) submissionFor unlisted nervous system surgery code 64999, submit supporting documentation to describe the services including history and physical with operative report or procedure report.

Risk of denialFailure to supply required documentation for unlisted codes may result in non-processing or denial.

RoutingSome unlisted procedure entries reference submission via Carelon per administrative instructions.

Carelon

Carelon vendorCarelon (provider portal https://providerportal.com/ or phone 1-800-859-5299) is the vendor/benefits management entity referenced for portal access and contact regarding listed CPT codes.

Guidelines linkMany entries include the Carelon guidelines URL (https://guidelines.carelonmedicalbenefitsmanagement.com/) for clinical criteria and routing.

Use caseProviders should use the Carelon portal/phone for prior authorization, guideline lookup, or administrative routing as indicated with each CPT entry.

Radiation Therapy

Radiation therapy categorizationEntries categorized as 'Radiation Therapy' identify CPTs related to radiation planning, delivery, or management (examples: 77295, 77402, 77432).

Carelon routingRadiation therapy codes are frequently paired with Carelon contact and guideline links for prior authorization and management.

Provider implicationSubmit required documentation and seek Carelon authorization where indicated for radiation therapy services.

Carelon/providerportal

Portal referenceDocument repeatedly references 'Carelon/providerportal' (https://providerportal.com/) and phone 1-800-859-5299 as the channel for prior authorization and administrative inquiries.

Guidelines URLGuidelines links (https://guidelines.carelonmedicalbenefitsmanagement.com/) are provided per code for clinical criteria and routing.

Submission instructionWhere indicated, providers should submit documentation via the Carelon portal or contact Carelon by phone for prior authorization and guidance.