Blue Cross Blue Shield NM plastic/reconstructive coverage update

Coverage Criteria and Per-code Designations

Coverage handling groups

Coverage handling by code as listed below (per-document logic: many codes require Clinical Review/Predetermination, some are EIU/excluded, some Non Covered, and unlisted codes may require contract/clinical review or prior authorization).

Clinical Review (Predetermination) required/recommended: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.

Applies to many CPT/HCPCS/T codes in this document (see code listings).

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

Billing EIU-designated procedures may result in denial.

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

Examples: select dental/gum and PLA/U codes listed as Non Covered.

Unlisted Procedure: Unlisted: Procedure/service not specifically defined or classified; may be subject to contract/clinical review or require prior authorization.

Providers should submit operative reports and justification for unlisted codes.

Coverage stances present in this segment

Coverage stance as listed per CPT/entry in this segment — many entries reference one of these stances:

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

Multiple CPTs in this segment are labeled MP Criteria; predetermination is recommended and some may require prior authorization per contract.

EIU (Excluded / Not reimbursed): EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review.

Several CPTs in this segment are marked EIU; check the EIU/CPCP policy for details.

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

Examples include numerous dental/gum procedures (41820–41874 range) and other codes explicitly labeled Non Covered.

Per-code review designations

Coverage and review stance is indicated per-code using these labels:

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

Applies to many CPT/HCPCS/T codes listed in this document (see code tables).

Unlisted procedures are not specifically defined or classified and may be subject to contract or clinical review.

Claims for unlisted codes typically require submission of operative reports and justification.

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

Billing EIU-designated procedures may result in denial.

Per-code coverage designations

Per-code coverage designations: Each listed code has an explicit designation in the table: 'Non Covered', 'EIU' (procedure/service not reimbursed), or 'MP Criteria' (requires review/predetermination).

This section is a coding table; medical necessity criteria are referenced via 'MP Criteria' entries requiring submission for clinical review.

Coverage designations (code-level)

Coverage designations present: Codes in this section are assigned one of: EIU (not reimbursed by the Plan; not subject to pre-service review), Non Covered (not covered), Unlisted (may be subject to contract/clinical review), MP Criteria (reviewed against Medical Policy Criteria; predetermination recommended).

Extracted verbatim designations per code; follow predetermination and documentation guidance for MP Criteria entries.

Code-level coverage designations

Coverage and review designations in this extract:

Predetermination required/recommended: Items marked 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.'

Applies to many E/M, CPT, HCPCS and temporary codes in this extract.

Unlisted/subject to contract or clinical review: Some codes flagged as 'Unlisted: Procedure/service not specifically defined or classified, may be subject to contract/clinical review and require supporting documentation.'

Providers should supply operative reports and justification when submitting unlisted codes.

Codes annotated EIU (experimental/investigational/unproven) are not reimbursed by the Plan and are excluded from coverage. Examples in this document include 17108, 20560, 20561, and 20985; these entries explicitly state EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review. Providers should not expect reimbursement for services reported with EIU-designated codes and should check the payer's EIU/CPCP guidance for details.

The code 21248 is explicitly designated Non Covered: Procedure/service not covered by the Plan. This designation indicates the service is not covered and is not subject to pre-service review.

Specific dental and gum procedure codes in this document (for example 41820, 41822, 41823, 41830, 41870, 41872, 41874) are labeled Non Covered: Procedure/service not covered by the Plan. These dental entries are identified as not covered and are not subject to predetermination (pre-service review).

Procedures annotated EIU in the code table are not reimbursed by the Plan and therefore excluded from coverage. Several endovenous and related CPT entries (for example 36473 and 36474) are marked EIU with the explicit note that they are not subject to pre-service review and will not be reimbursed.

Codes marked in the document as EIU: Procedure/service not reimbursed by the Plan are excluded from reimbursement. The policy language consistently notes that EIU entries (see multiple examples throughout the code lists) are not subject to pre-service review and should be treated as non‑reimbursable when billed.

Codes designated EIU in the table are procedures/services that the Plan does not reimburse. The listing indicates these codes are not subject to pre-service review; providers should refer to the Clinical Payment and Coding Policy (CPCP) for the EIU policy.

Specific codes are explicitly labeled Non Covered: Procedure/service not covered by the Plan. For example, the ophthalmology/eye‑related and certain laboratory/diagnostic entries shown include explicit Non Covered designations; those items are not subject to pre-service review and will not be reimbursed.

Where an item is annotated Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review, the Plan will not cover or reimburse the service and predetermination is not applicable. The document contains multiple such entries across specialties (laboratory, pathology, reproductive medicine, and others).

Services labeled EIU: Procedure/service not reimbursed by the Plan are excluded from reimbursement. The code list reiterates this designation across multiple ophthalmology and related codes; these entries are identified as not reimbursable and not subject to pre-service review.

Entries explicitly designated Non Covered in the table indicate the Plan will not provide coverage for those services. Such codes are listed across the document (including procedure and E/M groups) and are not subject to predetermination.

The document repeatedly marks certain items with EIU: Procedure/service not reimbursed by the Plan; those EIU‑flagged codes are excluded from reimbursement. The policy references the Clinical Payment and Coding Policy (CPCP) for the EIU designation and notes EIU services are not subject to pre-service review and may be denied if billed.

Codes that are explicitly labeled Non Covered: Procedure/service not covered by the Plan are excluded from coverage and are not subject to pre-service review. The listing includes multiple such Non Covered codes across different code groups.

Many codes in the U/T and related sections are explicitly indicated as either Non Covered or EIU. The document reiterates that these codes are excluded from reimbursement (EIU) or are not covered (Non Covered), and therefore billing these codes may result in denial.

Multiple PLA/Proprietary Laboratory Analysis codes in the 0154U–0162U series are explicitly labeled Non Covered: Procedure/service not covered by the Plan. The entries also note that prior authorization may be required per contract for some PLA codes, but the Non Covered designation means they are not reimbursed by the Plan.

Codes annotated EIU throughout the temporary (T) and other code lists are explicitly not reimbursed by the Plan. The T‑code sections contain multiple EIU flags; the policy language states these services are not subject to pre-service review and are excluded from reimbursement.

HCPCS A‑codes and other device/supply codes shown with the annotation EIU: Procedure/service not reimbursed by the Plan are explicitly not reimbursed. The document lists numerous A‑codes and supply items with EIU or Non Covered designations indicating exclusion from Plan reimbursement and that they are not subject to pre‑service review.

Across multiple sections the document uses the labels EIU or Non Covered to mark codes that the Plan excludes from reimbursement. When a code is annotated in this way, it is excluded from coverage and will not be reimbursed if billed.

The coding tables include many entries explicitly labeled Non Covered or EIU. Those designations indicate the services are excluded from reimbursement by the Plan and are not subject to pre-service review. Examples appear in dental (D‑codes), DME (E‑codes), and C‑code sections.

Numerous HCPCS E‑codes and equipment codes are specifically indicated as EIU and therefore not reimbursed by the Plan (examples in the extract include E0740, E0762, E0764, E0769, E0830, E0849, E0850, E0855, E0856, E0860, E0890, E0936, E0942, E0944, E1632, E1700–E1702). These entries reiterate the policy position that EIU‑flagged items are not reimbursable.

Codes marked EIU are consistently described as procedures/services not reimbursed by the Plan; the policy language across code listings confirms that EIU‑designated entries are effectively not covered and may be denied if billed.

CPT / HCPCS / C‑codes and Grouped Code Tables

Unlisted CPT codes (selected)CPT

68399	Unlisted procedure, conjunctiva
68899	Unlisted procedure, lacrimal system
69090	Pierce earlobes
69300	Revise external ear
69399	Unlisted procedure, external ear
69705	Nasal/surgical dilatation eustachian tube, unilateral
69706	Nasal/surgical dilatation eustachian tube, bilateral
69714	Implant, temporal bone, with stimulator
69716	Implant, osseointegrated implant small skin thickness <100
69717	Temporal bone implant revision

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Miscellaneous laboratory and pathology (examples)CPT

82523	Collagen crosslinks
83006	Growth stimulation gene
83695	Assay of lipoprotein(a)
83698	Assay lipoprotein PLA2
83701	Lipoprotein blood fraction
83704	Lipoprotein blood quantitative part
83722	Direct measurement LDL cholesterol
83937	Assay of osteocalcin
90378	RSV monoclonal antibody IM 50 mg
76496	Unlisted fluoroscopic procedure (see radiology group)

Psychiatry / Behavioral Health / Neurostimulation (selected)CPT

90867	Transcranial magnetic stimulation treatment planning
90868	Transcranial magnetic stimulation delivery
90869	TMS re-determination
90870	Electroconvulsive therapy
90875	Psychophysiological therapy
90876	Psychophysiological therapy, additional
90880	Hypnotherapy (non-covered)
90885	Psychiatric evaluation of records (non-covered)
90889	Preparation of report (non-covered)
90899	Unlisted psychiatric service/therapy

Neurodiagnostic / EEG / MEG / EMG (selected)CPT

90901	Biofeedback training, any method
90912	Biofeedback training first 15 minutes
90913	Biofeedback training each additional 15 minutes
91034	Gastroesophageal reflux test
91110	GI transit imaging intralumenal esophagointest
91111	GI transit intralumenal esophagus
91112	Wireless capsule GI measurement (EIU)
91117	Colon motility 6 hr study (EIU)
91132	Electrogastrography (EIU)
91133	Electrogastrography with test (EIU)

Ophthalmology / Audiology / Vision (selected)CPT

91299	Unlisted diagnostic GI procedure (listed here for consolidation)
92015	Determine refractive state (EIU/non-covered)
92065	Orthoptic training performed by physician/QHP (non-covered)
92132	Computer ophthalmic diagnostic imaging, anterior segment (EIU)
92145	Corneal hysteresis determination (EIU)
92340	Fit spectacles monofocal (non-covered)
92342	Fit spectacles multifocal (non-covered)
92354	Fit spectacles single system (non-covered)
92355	Fit spectacles compound lens (non-covered)
92370	Repair and adjust spectacles, unlisted ophthalmology

Hearing, Speech, and Swallowing (selected)CPT

92499	Unlisted ophthalmology service/procedure
92512	Nasal function studies (EIU)
92517	VEMP test cervical (EIU)
92518	VEMP test ocular (EIU)
92519	VEMP test combined (EIU)
92546	Sinusoidal rotational test
92548	CDP-SOT 6 condition with I&R (EIU)
92549	CDP-SOT 6 condition with I&R MCT & ADT (EIU)
92640	Assistive listening device fitting etc.
92700	Unlisted ear procedure examples consolidated

Cardiac / Vascular / Monitoring (selected)CPT

93050	Electrocardiogram 12 lead interpretation/report
93228	External mobile cardiovascular telemetry data review (EIU)
93229	Remote 30 day ECG technical support (EIU)
93702	Bis extravascular fluid analysis (EIU)
93740	Temperature gradient studies (EIU)
93797	Cardiac rehabilitation (EIU)
93798	Cardiac rehab/monitor (EIU)
93799	Unlisted cardiovascular service/procedure
93998	Unlisted noninvasive vascular diagnostic study
93999	(placeholder)

Pulmonary / Respiratory / Sleep (selected)CPT

94014	Patient recorded spirometry (EIU)
94015	Patient recorded spirometry (EIU)
94016	Review patient spirometry (EIU)
94452	HAST with report (non-covered)
94453	HAST oxygen titration (non-covered)
94799	Unlisted pulmonary service/procedure
95060	Eye allergy tests (EIU)
95065	Nose allergy tests (EIU)
95199	Unlisted allergy/immunology service/procedure

Neurophysiology / EEG / Sleep (selected)CPT

95700	EEG continuous recording with video EEG tech
95705	EEG without video 2-12 hr unmonitored
95706	EEG without video 2-12 hr intermittent
95707	EEG without video 2-12 hr continuous
95708	EEG without video each 12-26 hr unmonitored
95709	EEG without video each 12-26 hr intermittent
95710	EEG without video each 12-26 hr continuous
95711	VEEG 2-12 hr unmonitored
95803	Actigraphy testing
95905	Motor and sensory nerve conduction tests (EIU)

Neurodiagnostic advanced / MEG / Unlisted neuro (selected)CPT

95919	Quantitative pupillometry phys/QHP (EIU)
95954	EEG monitoring with drug administration
95957	EEG digital analysis
95965	MEG spontaneous
95966	MEG evoked
95999	Unlisted neurological diagnostic procedure
96000	Motion analysis video/3D
96001	Motion test with force pressure measurement
96002	Dynamic surface EMG
96003	Dynamic fine wire EMG

Therapies / Rehabilitation / PT/OT (selected)CPT

96379	Unlisted therapeutic/prophylactic/diagnostic injection/infusion
96549	Unlisted chemotherapy procedure
96913	UVA photochemotherapy
96922	Photochemotherapy laser treatment skin >500 sq cm
96931	Recombinant cellular/subcellular imaging skin
96999	Unlisted specialized dermatology service/procedure
97139	Unlisted modality/therapeutic procedure
97169	Athletic training evaluation (various) - see policy
97170	Athletic training evaluation - moderate complexity (non-covered)
97171	Athletic training evaluation - high complexity (non-covered)

Physical Medicine / Rehab / Devices (selected)CPT

97533	Sensory integration, community/work reintegration (non-covered)
97537	Community/work reintegration low frequency non-thermal ultrasound
97610	Low frequency non-thermal ultrasound (EIU)
97799	Unlisted physical medicine/rehab procedure
97139	Unlisted modality (duplicate group reference)
99024	Postoperative follow-up visit (non-covered)
99026	Postop follow-up in-hospital on-call (non-covered)
99027	Out-of-hospital on-call service (non-covered)
99050	Medical services after hours (unlisted)
99056	Medical service out of office (unlisted)

Predetermination, Prior Authorization, and Documentation

Prior Authorization

Predetermination / Prior Authorization recommendation

Submit for Recommended Clinical Review (Predetermination) to avoid post-service review for codes designated as MP Criteria or Clinical Review (Predetermination). Many procedures listed may also require Prior Authorization per the member's contract — check contract-specific requirements and obtain authorization when required. Use the payer's Utilization Management channels or Availity to submit predetermination/prior authorization requests.

Use Utilization Management channels or Availity for Recommended Clinical Review (Predetermination) requests.
Codes marked "MP Criteria" or "Clinical Review (Predetermination)" should be submitted prior to service to avoid post-service review/denial.
When a code is annotated "Prior Authorization may be required per contract agreement," verify member benefit plan and obtain prior authorization if the contract requires it.

Prior Authorization

Prior authorization recommended for select C‑codes; predetermination for unlisted C‑codes

Prior authorization may be required for select C‑codes and certain procedures flagged as MP Criteria; obtain authorization when contract requires it. For unlisted C‑codes, submit for Recommended Clinical Review (Predetermination) because unlisted items often trigger contract or clinical review — predetermination is recommended to avoid post‑service denial.

Background and Scope

Background: this section is an administrative code list rather than clinical guidance. It designates which procedures require medical policy review, predetermination, are non‑covered, experimental (EIU), or unlisted, and does not provide clinical indications or medical necessity criteria in this extract.

Key Definitions and Labels

MP Criteria — Procedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination).

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

ActionSubmit a Recommended Clinical Review (Predetermination) via Utilization Management or Availity prior to service when code is labeled 'MP Criteria'.

RiskFailure to submit predetermination for MP Criteria codes may result in post-service review or denial.

ScopeApplies to many CPT/HCPCS entries in this document (see code groups).

EIU — Experimental, investigational and unproven — procedure/service not reimbursed by the Plan; not subject to pre-service review.

Definition

OpenPayer

Plastic/Reconstructive surgery procedure coding and medical policy review list

Coverage Criteria and Per-code Designations

CPT / HCPCS / C‑codes and Grouped Code Tables

Predetermination, Prior Authorization, and Documentation

Background and Scope

Key Definitions and Labels