Blue Cross Blue Shield NM plastic/reconstructive Coverage Update

Coverage Criteria and Code-Level Classifications

MP Criteria / Predetermination

Codes are grouped by payer stance; coverage depends on meeting medical policy criteria and member contract terms.

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

Many plastic/reconstructive codes listed under MP Criteria require predetermination per entry

Non-Covered and Experimental/Unproven

Some services are explicitly excluded from reimbursement.

Non Covered / EIU: Procedure/service not covered by the Plan or considered experimental, investigational and unproven and therefore not reimbursed

Entries labeled Non Covered or EIU are not subject to pre-service review and will not be reimbursed

Coverage designations and required actions

Coverage and review expectations by code designation

MP Criteria codes: Codes marked 'MP Criteria' require submission for Recommended Clinical Review; predetermination is recommended to avoid post-service review.

Submit clinical documentation as indicated by code annotations.

EIU codes: Codes designated 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; check EIU/CPCP policy.

Do not submit for predetermination; billing of EIU codes may be denied.

Unlisted codes: Unlisted procedure codes are identified as 'Unlisted' or 'Unlisted or Undefined' and may be subject to contract/clinical review; prior authorization may be required per contract.

Providers should obtain prior authorization when indicated by contract.

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

Claims for Non Covered codes will be denied if billed as covered.

MP Criteria / Predetermination group

Coverage and review requirements as listed per code

MP Criteria - Recommended Clinical Review: Many listed CPT codes are reviewed against Medical Policy Criteria and require submission for Recommended Clinical Review; some explicitly recommend predetermination to avoid post-service review.

Examples include bariatric and select reconstructive procedure codes annotated with MP Criteria.

Excluded (EIU) procedures

Procedures not reimbursed by the Plan

EIU - Not reimbursed: Specific codes designated EIU are not reimbursed by the Plan and are not subject to pre-service review; refer to EIU policy.

Examples include transurethral RF treatment (53860), intracranial angioplasty (61630), epidural lysis codes (62263, 62264), and thermal destruction codes (64628, 64629).

Unlisted procedure review

Unlisted procedures may require contract or clinical review

Unlisted procedures: Unlisted CPT codes are identified as not specifically defined or classified and may be subject to contract or clinical review; predetermination is recommended in some cases.

Examples: 43999, 44238, 44799, 44979, 50549; prior authorization may be required per contract.

Not Medically Necessary / Non-covered

Non-covered codes: Some codes are explicitly labelled Non Covered (not reimbursed by the Plan).

Example: 65760 (Revision of cornea) is marked Non Covered.

MP Criteria (predetermination required)

Codes marked 'MP Criteria' require review

MP Criteria requirement: When a code is labeled 'MP Criteria' the service is reviewed against Medical Policy Criteria and providers must submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Some entries explicitly state predetermination is recommended or required; follow payer instructions and submit supporting documentation.

Non-covered codes

Per-code coverage/status designations

Non Covered: Codes explicitly labeled 'Non Covered: Procedure/service not covered by the Plan' are not reimbursed.

Referenced throughout chunks 144-151

EIU / Not reimbursed

Codes designated EIU

EIU - not reimbursed: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed; check referenced EIU/CPCP clinical policy for details.

Examples include multiple Category III/T and drug/device codes annotated as EIU.

MP Criteria

Codes reviewed under Medical Policy Criteria

MP Criteria - submit for review: Codes labeled 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review or denial.

Examples appear across procedural categories including device implantation and novel procedures (see annotated codes).

Coverage by code status (EIU vs MP Criteria)

Coverage stance determined by per-code status labels

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

Billing such codes will typically result in denial.

MP Criteria procedures: Codes labeled 'MP Criteria' require submission for Recommended Clinical Review (Predetermination) and are reviewed against Medical Policy Criteria.

Providers should follow predetermination instructions to avoid post-service review.

Effective/Retire date handling: Certain codes include explicit effective, add, or retire dates; coverage and review requirements may change on those dates.

Check code-specific date annotations (e.g., add effective 06/15/2023; retire effective 06/30/2023).

Coverage by code designation

Coverage/authorization approach by code designation

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

Examples are present among temporary (T) and HCPCS device codes.

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

Examples include selected Category III/T codes and device implant codes annotated MP Criteria.

Non-Covered code groups: Code groups labeled 'Non Covered' (e.g., administrative groups, OTC items) are explicitly non-covered and not subject to pre-service review.

These will be denied if billed as covered.

Coverage classifications

Codes in this extract are classified as follows based on annotations:

EIU (Not reimbursed): Codes annotated 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; providers should consult the Clinical Payment and Coding Policy (CPCP)

Examples: wound matrices and certain devices (A2001, A2002, A2004).

MP Criteria (Predetermination recommended): Codes annotated 'MP Criteria' require review against Medical Policy Criteria and submission for Recommended Clinical Review (Predetermination)

Examples include device and durable medical equipment codes annotated MP Criteria.

Non Covered: Codes annotated 'Non Covered' are not covered by the Plan and are not subject to pre-service review

Examples: supplies and miscellaneous items (A4553, A4554, A9150).

Unlisted/Clinical Review:

Predetermination-required items

Covered when submitted through Recommended Clinical Review

Predetermination requirement: For codes annotated 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' the provider must submit for Recommended Clinical Review (Predetermination) to avoid post-service review/denial.

Applies to the listed MP Criteria HCPCS/E-code entries and associated DME/device codes.

Not reimbursed / EIU items

Not covered (EIU)

EIU not reimbursed: Items labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and are not subject to pre-service review; see EIU policy or CPCP for details.

Examples include multiple durable equipment and device codes marked EIU (E0675, E0762, E0764, E0769, etc.).

Coverage designations and required actions

Coverage and review designations in this excerpt follow these patterns

MP Criteria codes: When a code is labeled 'MP Criteria', the procedure/service is reviewed against Medical Policy Criteria and providers should 'Submit for Recommended Clinical Review (Predetermination) to avoid post-service review' when that language is present.

Applies across many HCPCS E-code and SGD/device entries.

EIU codes: Codes annotated 'EIU' are identified as not reimbursed by the Plan and are not subject to pre-service review; check the payer's Clinical Payment and Coding Policy for details.

Billing EIU-coded items risks denial.

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

These items will be denied if submitted as covered services.

Example: codes labeled as EIU in the list (for example, 17340) are identified as EIU: Procedure/service not reimbursed by the Plan and therefore are not reimbursed. See EIU entries for laboratory and device codes flagged as EIU in the catalog.

Operational note: entries marked EIU are not subject to pre-service review; consult the EIU / Clinical Payment and Coding Policy (CPCP) for payment and coding guidance.

Example non-covered codes are explicitly annotated as Non Covered: Procedure/service not covered by the Plan. Illustrative entries include jaw reconstruction codes 21248 and 21249, and multiple dental/oral procedure codes such as 41820–41874, all listed as Non Covered.

Reminder: Non Covered designations indicate the service is not a benefit under the Plan and is not subject to pre-service review.

The EIU designation means Experimental, Investigational and Unproven — services so labeled are not reimbursed by the Plan. The policy states that EIU items are not subject to pre-service review and providers should check the EIU/CPCP guidance for additional details.

Examples across the list include procedure and product codes (e.g., select lab assays and device entries) flagged with the explicit note: EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.

A code annotated Non Covered indicates the service is not a covered benefit under the Plan and therefore is not subject to pre-service review. Billing such services as covered will generally result in denial.

Providers must confirm member-specific benefits in the member benefit booklet or with customer service because the presence of a code on this list does not itself change contract terms.

Codes designated either EIU or explicitly Non Covered are excluded from reimbursement: EIU codes will not be paid and Non Covered codes are not a Plan benefit. For example, vein treatment entries (e.g., some endovenous codes) and certain durable equipment entries are shown as excluded in the extract.

Because these designations remove reimbursement entitlement, submission of claims for such codes will typically result in denial under Plan rules.

Additional EIU examples include laboratory assays and wound/implant products annotated as EIU (see entries such as 82523 and wound matrix HCPCS like A2001). The policy repeatedly notes: EIU items are not reimbursed and not subject to pre-service review.

When EIU is indicated, providers should consult the Clinical Payment and Coding Policy (CPCP) for any coding guidance or clarification; EIU status is an exclusion from payment rather than a coverage criterion.

The list contains multiple explicit Non Covered examples, including cytology/autopsy codes (88000–88036, 88040, 88045, 88099) and blood-typing/paternity tests (86910, 86911) that are annotated as Non Covered: Procedure/service not covered by the Plan.

These entries reiterate that Non Covered services are not eligible for reimbursement and are not subject to predetermination review.

Many codes in the catalog are explicitly marked Non Covered; the document shows numerous examples among administration, care-management, and ancillary service codes (for example, post-op follow-up or certain remote monitoring and vaccine administration CPT/HCPCS codes).

The Plan treats these entries as exclusions — submitting these codes as covered services risks claim denial.

Continuing the Non Covered list, many vaccine administration and related codes (e.g., series of COVID administration codes such as 0001A–0054A) are annotated as Non Covered in the extract.

Similarly, several T- and U-code groups and other miscellaneous codes are either marked Non Covered or EIU, reinforcing the need to check per-code annotations before billing.

Additional Non Covered examples include durable medical supplies and miscellaneous items noted as not a Plan benefit (for example, under HCPCS items such as A4553 and non-prescription/experimental drug entries like A9150 annotated as Non Covered).

The document highlights that these supply and device codes are excluded and not subject to pre-service review.

A sample list of T- and U-codes are labeled EIU in the extract (for example, procedure-category T-codes introduced as EIU entries and specific U-codes flagged as EIU), demonstrating that temporary and new technology codes may be excluded from reimbursement pending policy review.

Be aware that many of these temporary codes also include effective/add or retire dates; check the date column for timing details before submission.

This segment of the index contains many codes explicitly labeled as Non Covered or EIU, reinforcing that a substantial portion of listed items are excluded from reimbursement or are investigational.

Operational guidance: presence on this list should prompt verification of member contract language because final coverage is determined by the member benefit contract.

Several code lines are shown with explicit EIU annotations (for example, multiple Category III/T codes and device entries), which the policy treats as not reimbursed by the Plan and not subject to pre-service review.

Where entries show both EIU and MP markers or date changes, the document clarifies the operational distinction between codes that are investigational (EIU) versus those reviewed under Medical Policy Criteria (MP Criteria).

This chunk documents Non Covered entries and notes surrounding EIU flags for various HCPCS E-codes and accessories; the extract repeatedly states that EIU codes are not reimbursed and Non Covered codes are not a Plan benefit.

Providers should therefore expect denial for services billed under codes explicitly annotated as EIU or Non Covered.

Wound matrices and many supply/product HCPCS codes appear in the list and are flagged either EIU or require submission under MP Criteria; the extract notes multiple wound product codes (e.g., A2001–A2019) with EIU or MP annotations.

For wound products and biologics, coding and payment guidance reference per-unit pricing (e.g., per sq cm) and the EIU/CPCP policy when EIU is indicated.

The document instructs that when an item is designated EIU, providers should check the EIU/CPCP policy for payment and coding guidance; EIU classification denotes non-reimbursement by the Plan.

This cross-reference to the Clinical Payment and Coding Policy is the operational route for clarifying EIU scope and reasoning.

Non Covered items are explicitly described in the policy as not subject to pre-service review and are not reimbursed if billed as covered services. The list includes many procedure, supply and administration codes in this status.

Providers should verify member-specific benefit contract terms because the presence of a code on this list does not itself change contract coverage determinations.

Chunk-level entries provide explicit examples of EIU items (lab assays and other procedures marked EIU). These examples illustrate the range of services labeled investigational that the Plan will not reimburse.

The EIU label is applied consistently across laboratory, device, and certain procedural code groups in the extract.

Summary: codes explicitly labeled Non Covered or EIU are excluded from reimbursement by the Plan; these status flags indicate claims for those services are not payable under Plan rules.

The document repeatedly emphasizes that EIU items are not subject to pre-service review and Non Covered items are not benefits under member contracts.

Caveat: the presence of a code on this index does not automatically determine benefit coverage — the member's benefit contract controls final coverage decisions. Providers must consult the member benefit booklet or customer service for contract-specific determination.

The policy is an administrative guide that ties code annotations to Plan payment stance but does not replace contract language.

Specific example: 65760 (revision of cornea) is shown as Non Covered: Procedure/service not covered by the Plan in this extract.

As a Non Covered item, it is not subject to predetermination and is not reimbursable under the Plan as listed.

Reference: full policy text and code table should be consulted for per-code status, effective/add/retire dates, and any prior authorization annotations not summarized here.

Examples of Non Covered items include miscellaneous supplies and non-prescription products such as wigs, exercise equipment, and certain nutritional or topical products listed as Non Covered in the extract.

These item-level Non Covered annotations reflect Plan exclusions for many over-the-counter/assistive items.

Code Groups and Code Tables

Mixed: MP Criteria / Non Covered / EIU / Unlistedmixed

11921	Correct Skin Color 6.0 cm/< — MP Criteria / Submit for Recommended Clinical Review
11922	Correct Skin Color addl — MP Criteria / Submit for Recommended Clinical Review
94015	PATIENT RECORDED (Spirometry) — EIU: Not reimbursed
96931	Rcm Celulr Subcelulr Img Skn — MP Criteria
96932	Rcm Celulr Subcelulr Img Skn — MP Criteria
96933	Rcm Celulr Subcelulr Img Skn — MP Criteria
96934	Rcm Celulr Subcelulr Img Skn — MP Criteria (Predetermination)
96935	Rcm Celulr Subcelulr Img Skn — MP Criteria
96936	Rcm Celulr Subcelulr Img Skn — MP Criteria (Predetermination)
99024	Postop Follow-Up Visit — Non Covered

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COVID-19 vaccine administration & related (Non Covered) / A, P, Q, T, U codesmixedNot Covered

0011A	ADM SARSCOV2 100MCG/0.5ML 1ST — Non Covered (Add effective 04/18/2023)
0012A	ADM SARSCOV2 100MCG/0.5ML 2ND — Non Covered (Add effective 04/18/2023)
0013A	ADM SARSCOV2 100MCG/0.5ML 3RD — Non Covered (Add effective 04/18/2023)
0051A	ADM SARSCV2 30MCG TRS-SUCR 1 — Non Covered (Add effective 04/18/2023)
0052A	ADM SARSCV2 30MCG TRS-SUCR 2 — Non Covered (Add effective 04/18/2023)
0053A	ADM SARSCV2 30MCG TRS-SUCR 3 — Non Covered (Add effective 04/18/2023)
0052U	LPOPRTN BLD W/5 MAJ CLASSES — EIU
0054T	BONE SRGRY CMPTR FLUOR IMAGE — EIU
0055T	BONE SRGRY CMPTR CT/MRI IMAG — EIU
0062U	AI SLE IGG&IGM ALYS 80 BMRK — EIU

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Provider Actions, Predetermination, and Denial Risk

Prior Authorization

Predetermination / Prior Authorization — MP Criteria

Prior Authorization and Predetermination: For codes annotated as MP Criteria, submit clinical documentation for a Recommended Clinical Review (Predetermination) to avoid post-service review or denial. Some MP Criteria items explicitly require Prior Authorization—verify member contract and obtain authorization when indicated.

Submit for Recommended Clinical Review (Predetermination) when code is labeled 'MP Criteria'.
Prior Authorization may be required for specific codes or per contract; obtain prior auth where noted to avoid claim denials.

Denial Risk

Not Reimbursed — EIU Codes

EIU-designated services are not reimbursed by the Plan and are not subject to pre-service review. Do not bill the plan for EIU items; claims will be denied. Refer to the EIU/CPCP policy for payment and coding guidance.

Codes flagged EIU (Experimental, Investigational, Unproven) are not reimbursed and will be denied if billed.

Definitions and Key Terms

MP Criteria — Procedure/service reviewed against Medical Policy Criteria

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

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

ScopeApplies to CPT/HCPCS codes annotated 'MP Criteria' across this code list (examples: 43772, 52327, 66180).

Non Covered — Procedure/service not covered by the Plan

DefinitionNon Covered: Procedure/service not covered by the Plan.

Pre-service reviewNot subject to pre-service review.

Consequence

Background and Scope

Background: This document is a code-level index used by the payer to indicate which plastic/reconstructive surgery and related procedure codes are subject to medical policy review, require Recommended Clinical Review (predetermination), are Non Covered, or are considered EIU.

It is intended as administrative guidance to support billing and utilization processes rather than a clinical practice guideline.

Policy Update Changes

2023-06-15code_addition

Several Category III/T codes (e.g., 0537T, 0538T, 0539T, 0540T) were added with an effective date of 06/15/2023

2023-07-01code_addition

Multiple temporary/Category III codes (e.g., 0632T) were added with an effective date of 07/01/2023

2023-09-01code_addition

At least one Category III code (0744T) was added with an effective date of 09/01/2023

OpenPayer

Recommended Clinical Review and Non-Covered Procedure Code List (Plastic/Reconstructive Surgery codes)