Blue Cross Blue Shield NM plastic/reconstructive Coverage Update

Coverage Criteria and Policy Dispositions

MP Criteria (Reviewed services)

Procedures are grouped by policy disposition and reviewed accordingly

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

codes listed with 'MP Criteria' require review; highlighted items may require prior authorization per contract.

Non Covered

Non Covered: Procedures/services not covered by the Plan; not subject to pre-service review.

Example: code 07957 listed as Non Covered.

EIU

Experimental/Investigational/Unproven (EIU): Procedures/services not reimbursed by the Plan; not subject to pre-service review; check EIU policy in the Clinical Payment and Coding Policy (CPCP).

Example: code 17340 flagged EIU.

Unlisted or Undefined

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

Examples: 15999, 17999.

Coverage annotations and review requirements (code-level)

Coverage stance and review notes for listed codes

MP Criteria required: Codes annotated 'MP Criteria' are to be reviewed against Medical Policy Criteria; providers should submit for Recommended Clinical Review to avoid post-service review.

Applied per-code in the coding table.

Prior authorization note: Some codes include the statement 'Prior Authorization may be required per contract agreement.' which indicates PA requirements vary by contract and must be checked.

Check member-specific contract for PA requirements.

Non-covered codes: Codes explicitly marked 'Non Covered' (e.g., 21248, 21249) are not covered by the Plan and are not subject to pre-service review.

Do not expect reimbursement for Non Covered codes.

EIU (Excluded from reimbursement):

Coverage designations

Coverage designations and required actions as listed

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

Many codes across specialties are labeled MP Criteria (see coding list).

EIU (Excluded): Procedure/service not reimbursed by the Plan; not subject to pre-service review; check EIU policy in Clinical Payment and Coding Policy (CPCP)

Examples include 28890, 30468, 30469, 36473, 36474, entries for 36836/36837.

Unlisted/Undefined: Unlisted procedures not specifically defined or classified; may be subject to contract/clinical review and prior authorization per contract

Many unlisted codes flagged (e.g., 25999, 29999, 33999, 37799).

Non-Covered:

Medical Policy Review Requirement

Covered/Review logic per code flags in this excerpt

MP Criteria requirement: If a code entry is labeled 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria', submit for Recommended Clinical Review to avoid post-service review.

Operational requirement to submit recommended clinical review when MP Criteria appears.

Coverage flags and review requirements

Coverage notes by code flag

MP Criteria codes: Codes labeled 'MP Criteria' require review against the payer's Medical Policy Criteria; providers should submit for Recommended Clinical Review to avoid post-service review.

Applied per-code as listed.

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

Applied per-code as listed.

Unlisted procedure codes may be subject to contract or clinical review and prior authorization per contract.

Providers should supply supporting documentation for unlisted codes.

Per-code coverage statuses

per-code status: Codes are assigned one of: EIU (not reimbursed by Plan; not subject to pre-service review), MP Criteria (procedure reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review), Non Covered, or Unlisted (may be subject to contract/clinical review)

Statuses applied individually per code as listed in document

MP Criteria (requires review)

Coverage designations in this extract follow these patterns

MP Criteria: Items labeled 'MP Criteria' are reviewed against Medical Policy Criteria and providers are instructed to 'Submit for Recommended Clinical Review to avoid post-service review.'

Use recommended clinical review submission to reduce post-service review risk.

EIU (Excluded; not reimbursed)

EIU: Items labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; check the Clinical Payment and Coding Policy (CPCP).

These services will not be paid under the Plan.

Non Covered

Non Covered: Items labeled 'Non Covered' are not covered by the Plan and are not subject to pre-service review; prior authorization language may still appear for some codes but Non Covered means not payable.

Do not expect coverage for Non Covered codes.

Coverage stances present in this chunk

Coverage designations in this section follow these stances:

Non Covered/EIU: Codes explicitly labeled 'Non Covered' or 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed by the Plan and are not subject to pre-service review.

Examples: temporary T/U codes and selected HCPCS entries.

MP Criteria (Recommended Clinical Review): Codes labeled 'MP Criteria' should be submitted for Recommended Clinical Review to avoid post-service review; coverage depends on review outcome.

See coding list for per-code application.

Prior Authorization: Prior authorization may be required per contract agreement for certain codes not designated EIU/Non Covered; check contract specifics.

Statement repeated across code lines.

Coverage annotations (MP Criteria vs EIU/Non Covered)

Coverage annotations in this excerpt fall into two patterns:

MP Criteria: When a code entry is annotated 'MP Criteria', the procedure/service is reviewed against Medical Policy Criteria and providers should submit for Recommended Clinical Review to avoid post-service review.

Applied to numerous T-codes and other entries (see coding list).

EIU / Non Covered: Codes annotated 'EIU' or 'Non Covered' are not reimbursed by the Plan and are not subject to pre-service review; check the EIU/CPCP policy for details.

Applied to many A20xx and 213xx codes.

Coverage status by code annotation

Coverage and review rules as indicated per code

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

Examples: A2011, A2012, A2013, A2016, A2017, A2018, A2019.

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

Examples: A4927, A4931, A4932, A9150, A9152, A9153, A9270, A9282, A9300.

MP Criteria / Recommended Clinical Review: Codes marked 'MP Criteria' require submission for Recommended Clinical Review to avoid post-service review.

Examples across A-, C- codes and C9257.

Background: this document groups CPT/HCPCS procedure codes by policy disposition (e.g., MP Criteria, EIU, Non Covered, Unlisted) to give administrative guidance for claims review, prior‑authorization checks, and Recommended Clinical Review submissions. The primary purpose is to indicate per‑code coverage stance and the provider actions (submit for review or expect nonpayment) associated with each annotation.

The codes 21248 and 21249 are explicitly annotated in the coding table as Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review. When billed these codes will not be reimbursed by the Plan and are not eligible for pre-service authorization.

Entries marked EIU are excluded from reimbursement and the Plan will not pay claims for those services. Examples in this document include 28890 (HI ENERGY ESWT plantar fascia), 30468 and 30469 (nasal valve repair entries), 36473 and 36474 (endovenous mechanical/chemical add-on entries), and other EIU‑flagged items shown in the coding lists.

Procedures labeled "EIU: Procedure/service not reimbursed by the Plan" are excluded from reimbursement and not subject to pre-service review. Where an EIU annotation appears the table directs providers to consult the EIU guidance in the Clinical Payment and Coding Policy (CPCP) for additional detail and to confirm that the service is not payable under the Plan.

Codes explicitly labeled Non Covered in the coding table are excluded from coverage. These entries (for example 29440 and multiple vaccine and supply codes in the vaccine/HCPCS segments) state "Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review." Claims for such codes may be denied when submitted.

CPT / HCPCS Code Lists and Status

Unlisted / Unspecified CPT/HCPCS (select)mixed

43289	UNLISTED LAPS PX ESOPH (Unlisted: subject to contract/clinical review).
43499	UNLISTED PROCEDURE ESOPHAGUS (Unlisted: subject to contract/clinical review).
43659	UNLISTED LAPS PX STOMACH (Unlisted: subject to contract/clinical review).
43999	UNLISTED PROCEDURE STOMACH (Unlisted: subject to contract/clinical review).
44238	UNLISTED LAPS PX INTESTINE (Unlisted: subject to contract/clinical review).
44799	UNLISTED PX SMALL INTESTINE (Unlisted: subject to contract/clinical review).
44899	UNLISTED PX MECKEL'S DVRTCLM (Unlisted: subject to contract/clinical review).
44979	UNLISTED LAPS PX APPENDIX (Unlisted: subject to contract/clinical review).
45399	UNLISTED PROCEDURE COLON (Unlisted: subject to contract/clinical review).
45499	LAPAROSCOPE PROC RECTUM (Unlisted: subject to contract/clinical review).

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Non Covered exampleCPTNot Covered

43206	ESOPH OPTICAL ENDOMICROSCOPY — EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.
43252	EGD OPTICAL ENDOMICROSCOPY — EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.
43290	EGD FLX TRNSORL DPLMNT BALO — EIU: Procedure/service not reimbursed by the Plan. (Add effective 01/01/2023).
43291	EGD FLX TRNSORL RMVL BALO — EIU: Procedure/service not reimbursed by the Plan. (Add effective 01/01/2023).

Experimental / Investigational / Unproven (EIU)CPTExperimental

88375	OPTICAL ENDOMICROSCPY INTERP — EIU: Procedure/service not reimbursed by the Plan.
86328	IA NFCT AB SARSCOV2 COVID19 — EIU: Procedure/service not reimbursed by the Plan (Add effective 06/01/2023).
86408	NEUTRLZG ANTB SARSCOV2 SCR — EIU: Procedure/service not reimbursed by the Plan (Add effective 06/01/2023).

Unlisted / Undefined codes (excerpt)CPT

15999	UNLISTED PX EXC PRESSURE ULC — Unlisted: may be subject to contract/clinical review.
17999	UNLISTD PX SKN MUC MEMB SUBQ — Unlisted: may be subject to contract/clinical review.

Breast surgery codes (selected)CPT

19300	REMOVAL OF BREAST TISSUE — MP Criteria: submit for clinical review.
19303	MAST SIMPLE COMPLETE — MP Criteria: submit for clinical review.
19350	(see source) — submit for Recommended Clinical Review to avoid post-service review.
19499	UNLISTED PROCEDURE BREAST — MP Criteria: unlisted/subject to review.

Head/Face/Maxillofacial & related (selected)CPT

21089	UNLISTED MAXLFCL PROSTH PX — Unlisted: may be subject to contract/clinical review.
21120	RECONSTRUCTION OF CHIN — MP Criteria: submit for clinical review.
21127	Augmentation Lower Jaw Bone — MP Criteria: prior auth may be required.
21299	UNLISTED CRANFCL&MAXLFCL — Unlisted: subject to review.

Extensive craniofacial / maxillofacial (examples)CPT

21206	Reconstruct Upper Jaw Bone — MP Criteria: prior auth may be required.
21248	RECONSTRUCTION OF JAW — Non Covered in source excerpt.
21249	RECONSTRUCTION OF JAW — Non Covered in source excerpt.
21499	UNLISTED MUSCSKEL PX HEAD — Unlisted: subject to review.

Musculoskeletal / Spine / Extremity (selected)CPT

22505	MANIPULATION OF SPINE — MP Criteria: submit for clinical review; prior auth may be required.
22526	IDET SINGLE LEVEL — EIU: not reimbursed.
22899	UNLISTED PROCEDURE SPINE — Unlisted: may be subject to review.
22999	UNLISTED PX ABDOMEN MUSCSKEL — Unlisted: may be subject to review.

Mixed procedure examplesCPT

29999	UNLISTED PX ARTHROSCOPY — MP Criteria: submit for clinical review.
30999	UNLISTED PROCEDURE NOSE — Unlisted: prior auth may be required.

Ankle / Leg / Foot (selected)CPT

27860	FIXATION OF ANKLE JOINT — MP Criteria: submit for clinical review.
28890	HI ENRGY ESWT PLANTAR FASCIA — EIU: not reimbursed.
27899	UNLISTED PX LEG/ANKLE — Unlisted: subject to review.

Arthroscopy / Hip / Nasal (examples)CPT

29866	AUTGRFT IMPLNT KNEE W/SCOPE — MP Criteria: submit for clinical review.
29914	HIP ARTHRO W/FEMOROPLASTY — MP Criteria: submit for clinical review.

Cardiac / Pulmonary (selected)CPT

33211	INSERT CARD ELECTRODES DUAL — MP Criteria: submit for clinical review.
33542	(see source) — submit for Recommended Clinical Review to avoid post-service review.
33999	UNLISTED PX CARDIAC SURGERY — MP Criteria: unlisted/subject to review.

Cardiac surgery and vascular unlisted (examples)CPT

36299	UNLISTED PX VASCULAR NJX — Unlisted: subject to review.
37215	TRANSCATH STENT CCA W/EPS — MP Criteria: submit for clinical review.
37244	(see source) — submit for Recommended Clinical Review to avoid post-service review.

Vein treatment and endovenous proceduresCPT

36479	ENDOVENOUS LASER 1ST VEIN — MP Criteria: submit for clinical review.
36482	ENDOVEN THER CHEM ADHES 1ST — MP Criteria: submit for clinical review.
36483	ENDOVEN THER CHEM ADHES SBSQ — MP Criteria: submit for clinical review.
36836	PRQ AV FSTL CRTJ UXTR 1 ACS — EIU: not reimbursed (add effective 01/01/2023).

Stem cell / bone marrow harvest and processing (selection)CPT

38206	HARVEST AUTO STEM CELLS — MP Criteria: submit for clinical review; prior auth may be required.
38205	HARVEST ALLOGENEIC STEM CELL — MP Criteria: submit for clinical review.
38230	BONE MARROW HARVEST ALLOGEN — MP Criteria: prior auth may be required.
38232	BONE MARROW HARVEST AUTOLOG — MP Criteria: submit for clinical review.

GI / Bariatric / Abdominal surgery (selected)CPT

43236	UPPR GI SCOPE W/SUBMUC INJ — MP Criteria: submit for clinical review.
43284	LAPS ESOPHGL SPHNCTR AGMNTJ — MP Criteria: submit for clinical review.
43632	REMOVAL OF STOMACH — MP Criteria: submit for clinical review (Add effective 06/01/2023).
43633	REMOVAL OF STOMACH PARTIAL — MP Criteria: submit for clinical review.
43644	LAP GASTRIC BYPASS/ROUX-EN-Y — MP Criteria: submit for clinical review.
43645	LAP GASTR BYPASS INCL SMLL I — MP Criteria: submit for clinical review.
43770	LAP PLACE GASTR ADJ DEVICE — MP Criteria: submit for clinical review.
43771	LAP REVISE GASTR ADJ DEVICE — MP Criteria: submit for clinical review.
43772	LAP RMVL GASTR ADJ DEVICE — MP Criteria: submit for clinical review.
43774	LAP RMVL GASTR ADJ ALL PARTS — MP Criteria / submit for review.

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General surgery / unlisted abdomen (examples)CPT

49329	UNLSTD LAPS PX ABD PERTM&OMN — Unlisted: subject to review.
49659	UNLSTD LAPS PX HRNAP HRNRPHY — Unlisted: subject to review.
49999	UNLISTED SURGICAL PROCEDURE — Unlisted: subject to review.

Urologic / Genital (selected)CPT

50250	CRYOABLATE RENAL MASS OPEN — MP Criteria: submit for clinical review.
50360	TRANSPLANTATION OF KIDNEY — MP Criteria: submit for clinical review.
50592	PERC RF ABLATE RENAL TUMOR — MP Criteria: submit for clinical review.
50593	PERC CRYO ABLATE RENAL TUM — MP Criteria: submit for clinical review.
51715	ENDOSCOPIC INJECTION/IMPLANT — MP Criteria: submit for clinical review.
52327	CYSTOSCOPY INJECT MATERIAL — MP Criteria: submit for clinical review.
52441	CYSTOURETHRO W/IMPLANT — MP Criteria: submit for clinical review.
52442	CYSTOURETHRO W/ADDL IMPLANT — MP Criteria: submit for clinical review.
53860	TRANSURETHRAL RF TREATMENT — MP Criteria: EIU in source excerpt.
53855	INSERT PROST URETHRAL STENT — MP Criteria: submit for clinical review.

Male / Female genital and gender transformation (selection)CPT

54125	REMOVAL OF PENIS — MP Criteria: submit for clinical review.
54200	TREATMENT OF PENIS LESION — MP Criteria: submit for clinical review.
54205	TREATMENT OF PENIS LESION — MP Criteria: submit for clinical review.
54235	Penile Injection — MP Criteria: submit for clinical review.
54400	INSERT SEMI-RIGID PROSTHESIS — MP Criteria: submit for clinical review.
54401	INSERT SELF-CONTD PROSTHESIS — MP Criteria: submit for clinical review.
54405	INSERT MULTI-COMP PENIS PROS — MP Criteria: submit for clinical review.
54660	REVISION OF TESTIS — MP Criteria: submit for clinical review.
55880	ABLTJ MAL PRST8 TISS HIFU — MP Criteria: submit for clinical review.
55970	SEX TRANSFORMATION M TO F — MP Criteria: submit for clinical review.

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Gynecology / obstetrics (selected)CPT

57291	CONSTRUCTION OF VAGINA — MP Criteria: submit for clinical review.
57292	CONSTRUCT VAGINA WITH GRAFT — MP Criteria: submit for clinical review.
58578	UNLISTED LAPS PX UTERUS — Unlisted: subject to review.
58579	UNLISTED HYSTSC PX UTERUS — Unlisted: subject to review.
58999	UNLISTED PX FML GENITAL SYS — Unlisted: subject to review.

Neurology / Neurointerventional (selected)CPT

61630	INTRACRANIAL ANGIOPLASTY — EIU in source excerpt.
61635	INTRACRAN ANGIOPLSTY W/STENT — MP Criteria: submit for clinical review.
62263	EPIDURAL LYSIS MULT SESSIONS — EIU: not reimbursed.
62264	EPIDURAL LYSIS ON SINGLE DAY — EIU: not reimbursed.
64582	(see source) — submit for Recommended Clinical Review to avoid post-service review.
64628	TRML DSTRJ IOS BVN 1ST 2 L/S — EIU: not reimbursed.
64629	TRML DSTRJ IOS BVN EA ADDL — EIU: not reimbursed.

Ophthalmology / Eye codes (selected)CPT

65760	REVISION OF CORNEA — Non Covered in source excerpt.
65770	REVISE CORNEA WITH IMPLANT — MP Criteria: submit for clinical review.
66174	TRLUML DIL AQ O/F CAN W/O ST — MP Criteria: submit for clinical review.
66175	TRLUML DIL AQ O/F CAN W/ST — MP Criteria: submit for clinical review.
66179	AQUEOUS SHUNT EYE W/O GRAFT — MP Criteria: submit for clinical review.
66180	AQUEOUS SHUNT EYE W/GRAFT — MP Criteria: submit for clinical review.
66989	XCPSL CTRC RMVL CPLX INSJ 1+ — MP Criteria: submit for clinical review.
67900	REPAIR BROW DEFECT — MP Criteria: prior auth may be required.

Optical endomicroscopy / pathology (examples)CPTExperimental

88375	OPTICAL ENDOMICROSCPY INTERP — EIU: not reimbursed.
43206	ESOPH OPTICAL ENDOMICROSCOPY — EIU: not reimbursed.
43252	EGD OPTICAL ENDOMICROSCOPY — EIU: not reimbursed.

Laboratory / Molecular / Genetic (selected)CPT

81479	UNLISTED MOLECULAR PATHOLOGY — Unlisted: may require prior auth.
86328	IA NFCT AB SARS-COV2 COVID19 — EIU: not reimbursed (effective 06/01/2023).
86409	NEUTRLZG ANTB SARS-COV2 TITER — EIU: not reimbursed (effective 06/01/2023).
86343	LEUKOCYTE HISTAMINE RELEASE — EIU: not reimbursed.

HCPCS / C-codes / Drugs / Devices (selected)HCPCS

C9257	Bevacizumab injection — MP Criteria: submit for clinical review; prior auth may be required.
C9354	Veritas collagen matrix cm2 — EIU: not reimbursed in source excerpt.
C5271	Low cost skin substitute app — MP Criteria: submit for review (Add effective 04/01/2023).
A0426	Ambulance Service — MP Criteria: submit for clinical review.

EIU / Non-covered temporary / T-codes (examples)mixedExperimental

0052U	LPOPRTN BLD W/5 MAJ CLASSES — EIU: not reimbursed.
0087U	Crd Hrt Trnspl Mrna 1283 Gen — Non Covered / prior auth may be required.
0224U	ANTIBODY SARS-COV-2 TITER(S) — EIU / Non Covered (Add effective 06/01/2023).

Unlisted supply / DME / miscellaneous HCPCS (selected)HCPCS

A9270	Non-covered item or service — Non Covered.
A9279	Monitoring feature/device NOS — Unlisted: may be subject to review.
A9999	DME supply or accessory NOS — Unlisted: may be subject to review.

Actions for Providers — Prior Authorization, Review, Documentation

Prior Authorization

Recommended Clinical Review required for MP Criteria codes

Some procedure codes on this list are reviewed against Medical Policy Criteria (annotated "MP Criteria"). Submit these cases for Recommended Clinical Review to avoid post-service review. When an entry is labeled MP Criteria, providers should include documentation that supports medical necessity and follow Recommended Clinical Review submission instructions.

Submit for Recommended Clinical Review for codes annotated "MP Criteria" to avoid post-service review.
Include clinical documentation supporting medical necessity when submitting MP Criteria cases.

Note

Presence of codes on this list does not indicate coverage

The presence of a code on this list does not necessarily mean the service is covered under a member's benefit contract. Member benefit plans differ; verify coverage in the member benefit booklet or by contacting customer service before providing service.

Background and Scope

This coding table groups procedure codes by their policy disposition to guide coverage determination and billing. Codes annotated MP Criteria are reviewed against the payer's Medical Policy Criteria and providers are instructed to submit for Recommended Clinical Review to avoid post-service review. Codes annotated EIU (Experimental/Investigational/Unproven) or Non Covered indicate the procedure/service is not reimbursed by the Plan and are not subject to pre-service review; check the EIU/CPCP documentation where directed. Providers should verify member-specific contract rules because some codes may still require prior authorization per contract.

Definitions and Term Clarifications

MP Criteria — definition and implications

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

Coverage implicationCodes annotated 'MP Criteria' are evaluated against the payer's medical policy and coverage depends on meeting those criteria.

Provider actionProviders should submit for Recommended Clinical Review (pre-service) when MP Criteria is indicated to reduce risk of post-service denial.

EIU — definition

DefinitionEIU (Experimental, Investigational and Unproven): Procedures/services not reimbursed by the Plan and not subject to pre-service review.

Documentation note

Policy Revision History and Material Changes

2023-06-15codes_added

Multiple temporary T-codes (e.g., 0766T–0768T, 0772T, 0773T, 0774T, 0779T, 0793T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T–0808T) and A-codes (A2001–A2015) were added with mid-2023 effective dates; several of these entries include retire/short effective windows noted (e.g., add 06/15/2023; retire 06/30/2023 or 08/31/2023).

2023-07-01codes_status_update

Some T-codes (for example entries with add effective 07/01/2023) were added or had status entries referencing 07/01/2023 effective dates and short retire windows in mid-2023.

2023-09-01codes_added

OpenPayer

Plastic/Reconstructive surgery procedure coding and medical policy grouping