Blue Cross Blue Shield NM procedure code coverage | OpenPayer
CurrentBlue Cross Blue Shield - New MexicoPolicy N/A
Recommended Clinical Review (Predetermination), Post-Service Review and Non-Covered 2023 Commercial Benefit Procedure Code List
A payer-maintained list of CPT/HCPCS procedure codes indicating which services require medical policy review, recommended predetermination, are non-covered, or considered experimental/investigational for Blue Cross Blue Shield - New Mexico commercial products.
Policy Summary
PayerBlue Cross Blue Shield - New Mexico
PolicyCommercial Benefit Procedure Code List (2023)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateMarch 2023
Next Review DateN/A
Key ActionSubmit for Recommended Clinical Review (Predetermination) when a code is labeled 'MP Criteria' to avoid post-service review.
No material clinical or coverage changes in this revision.
2023publication year
MP Criteria / Non Covered / EIUcoverage categories
Mar 2023posting date
Multiplecodes requiring predetermination
Severalcodes marked EIU
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Coverage Criteria and Code Annotations
Predetermination / MP Criteria
Predetermination / Medical Policy (MP) Criteria: Procedures/services listed as "MP Criteria" are reviewed against Medical Policy criteria. Providers should submit for Recommended Clinical Review (Predetermination) to avoid post-service review. Some services may also require prior authorization per the member's contract.
ALL of the following
Procedure/service is designated 'MP Criteria' in the code list (subject to Medical Policy review).
A Recommended Clinical Review (Predetermination) request should be submitted prior to service to reduce risk of post-service denial.
Follow the referenced Medical Policy number(s) and title(s) for clinical criteria (example: SUR716.003 Bariatric Surgery; THE803.016 Manipulation Under Anesthesia).
Some MP Criteria entries note that Prior Authorization may be required per contract — check member benefit and contract-specific authorization rules.
Excluded / Experimental, Investigational, Unproven (EIU) and Non-Covered
Excluded / Experimental, Investigational, Unproven (EIU) and Non-Covered: Codes marked as EIU are not reimbursed by the Plan and are not subject to pre-service review. Codes marked 'Non Covered' are not benefits under the Plan and are not subject to pre-service review. 'Unlisted' codes may be subject to contract or clinical review.
ALL of the following
Codes labeled 'EIU' (Experimental, Investigational, Unproven) are not reimbursed by the Plan; these services are not subject to pre-service review. Refer to CPCP EIU policy (e.g., ADM1001.032) for details.
Codes labeled 'Non Covered' are excluded from benefits under the Plan and are not subject to pre-service review. Examples include dental/gum procedures (41820-41830 series), autopsy gross procedures (88000 series), and certain vision/spectacle fittings (92341-92355).
'Unlisted' or 'Unlisted Procedure' entries are services not specifically defined or classified and may be subject to contract or clinical review; prior authorization may be required per contract.
Some codes may appear with both an EIU designation and additional notes such as an effective/ending date — observe effective dates for applicability (e.g., 30469 add effective 01/01/2023).
Coverage stance by code designation
Coverage stance by code designation — per-code flags and guidance: Each code in the extract is assigned one of the following coverage designations. The code list groups codes by these designations and may include referenced Medical Policy numbers and titles.
ANY of the following
MP Criteria: Procedure/service reviewed against Medical Policy Criteria — recommend Predetermination to avoid post-service review. May include 'Prior Authorization may be required per contract agreement.'
EIU: Experimental, Investigational and/or Unproven — Procedure/service not reimbursed by the Plan; not subject to pre-service review; see CPCP EIU policy references (e.g., ADM1001.032).
Non Covered: Procedure/service not covered by the Plan; not subject to pre-service review.
Unlisted: Procedure/service not specifically defined or classified; may require contract/clinical review or prior authorization per contract.
Coverage designation categories
Coverage designation categories present in this extract — how codes are grouped in the list: The document groups codes into coverage categories and annotates per-code flags and references.
ALL of the following
Major coverage designation groups in the extract: MP Criteria (Predetermination), EIU (Experimental/Investigational/Unproven), Non Covered, and Unlisted/Undefined.
Per-code entries commonly include: code, short description, designation (MP Criteria / EIU / Non Covered / Unlisted), Medical Policy number(s) and title(s), effective/ending dates, and optional notes (e.g., 'Prior Authorization may be required per contract agreement').
The list consolidates codes by service area (surgery, radiology, lab, DME, HCPCS/C-codes) and provides policy references for clinical criteria when applicable.
Coverage annotation categories
Coverage annotation categories and per-code flags (examples consolidated from extract): The following annotations appear across the code list and indicate coverage action or follow-up required.
ALL of the following
'MP Criteria' — submit for Recommended Clinical Review (Predetermination); check referenced Medical Policy number(s) for clinical criteria.
'EIU' — not reimbursed by the Plan; not subject to pre-service review; see CPCP EIU policy (e.g., ADM1001.032, SUR712.024).
'Non Covered' — not a benefit; not subject to pre-service review (examples: skin tag removal codes 11200/11201; dental/gum procedures 41820–41874; autopsy codes 88000–88012; spectacle fittings 92341–92370).
'Unlisted' — may require contract/clinical review or prior authorization; entries flagged 'Unlisted Procedure' (e.g., 17106, 17999, many 99xxx codes) should be handled per contract and clinical review process.
Coverage contingent on meeting Medical Policy Criteria and Predetermination
Coverage contingent on meeting Medical Policy Criteria and Predetermination: When a code is designated MP Criteria, payment is contingent on meeting the clinical criteria described in the referenced Medical Policy and on completing any required predetermination process.
ALL of the following
For MP Criteria codes, a Predetermination (Recommended Clinical Review) is recommended to document medical necessity against the referenced Medical Policy; lacking predetermination may lead to post-service review and possible denial.
Providers should reference the specific Medical Policy number(s) cited in the code entry (examples include SUR707.016 Varicose Vein Management, SUR716.003 Bariatric Surgery, THE803.016 Manipulation Under Anesthesia) to ensure criteria are met prior to service.
If an entry also indicates prior authorization per contract, obtain authorization per the member's benefit plan before providing the service.
MP Criteria (Predetermination)
MP Criteria (Predetermination) — operational notes and action items: Submit predetermination requests via the insurer's Utilization Management channels (website or Availity) and include necessary documentation tied to the referenced Medical Policy.
ALL of the following
Submit Recommended Clinical Review (Predetermination) requests through the payer's Utilization Management process or via Availity (https://www.availity.com/).
Include clinical documentation demonstrating how the patient meets the referenced Medical Policy criteria and cite the Medical Policy number(s) listed in the code entry.
Predetermination reduces risk of post-service denials but does not guarantee coverage — final determination is based on member benefit contract and policy criteria.
Coverage categories by code designation
Coverage categories by code designation — per-code coverage flags consolidated (representative examples): This grouping consolidates typical per-code flags shown repeatedly across the extract.
Unclassified drugs or biologicals (may require prior auth)
A9999
DME supply or accessory NOS
D9999
Unspecified adjunctive dental procedure by report
90749
Unlisted vaccine/toxoid
99499
Unlisted E&M service
Selected EIU / Not Reimbursed Codes (examples)mixedExperimental
17360
Cryotherapy of skin — EIU (not reimbursed)
28890
High energy ESWT plantar fascia — EIU
41130
(example placeholder)
61630
Intracranial angioplasty (EIU)
Provider Instructions, Predetermination and Prior Authorization
Prior Authorization
Submit Predetermination for MP Criteria codes
Codes labeled 'MP Criteria' require submission for Recommended Clinical Review (Predetermination) prior to service to avoid post-service review.
Submit predetermination via Utilization Management on payer website or Availity (see instructions).
Prior Authorization
Prior authorization may be required — check contract
Some listed procedures may also require prior authorization per the member's contract; check contract-specific prior authorization requirements before scheduling.
Example: code 19316 notes 'Prior Authorization may be required per contract agreement.'
The header and background explain the role of MP Criteria: codes labeled MP Criteria are 'Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post‑service review.' This applies to many listed codes and is the operational instruction when a code is not administratively excluded.
Key Definitions and Abbreviations
MP Criteria definition
MP Criteria (definition)Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.
Associated actionProviders should submit documentation for predetermination when a code is labeled 'MP Criteria'
ReferenceLinked medical policy IDs are provided alongside codes (e.g., SUR716.001, SUR707.025)
Non Covered definition
Non Covered (definition)Procedure/service not covered by the Plan. Not subject to pre-service review.
ImplicationClaims for Non Covered services will be denied; member benefit booklet should be consulted for exceptions
Policy Summary
PayerBlue Cross Blue Shield - New Mexico
PolicyCommercial Benefit Procedure Code List (2023)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateMarch 2023
Next Review DateN/A
Key ActionSubmit for Recommended Clinical Review (Predetermination) when a code is labeled 'MP Criteria' to avoid post-service review.
Per-code 'Prior Authorization may be required per contract agreement' — when noted in the entry, follow member-specific authorization rules even if MP Criteria is indicated (examples: 21146, 21159, 38206).
When a code is marked 'MP Criteria' submit for Recommended Clinical Review (Predetermination); prior authorization may be required per contract for some services.
Denial Risk
EIU entries — not reimbursed
Codes designated EIU (Experimental/Investigational/Unproven) are not reimbursed by the Plan and are not subject to pre-service review; submitting these services may result in denial.
Example: 30469 is listed EIU with add effective date 01/01/2023.
Prior Authorization
Predetermination advised for many listed codes
Many procedure codes annotated 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review; some of these may also require prior authorization per contract.
Prior Authorization
Predetermination recommended (HCT and others)
Submit for Recommended Clinical Review (Predetermination) when codes are labeled 'MP Criteria' to avoid post-service review; prior authorization may be required per contract for some services (e.g., hematopoietic cell transplantation codes).
Example: 38206 indicates prior authorization may be required per contract.
Prior Authorization
Predetermination required for MP Criteria entries
Certain codes are specifically designated 'MP Criteria' — submit for Recommended Clinical Review (Predetermination) before service to avoid post-service review and potential denial.
Examples include bariatric and related GI procedure CPTs listed with MP Criteria.
Prior Authorization
Prior authorization may be required for certain device implants
Some implantable-device procedures may require prior authorization per contract in addition to predetermination review (example provided in list).
Example: code 64582 notes 'Prior Authorization may be required per contract agreement.'
Prior Authorization
Predetermination recommended for MP Criteria codes (examples)
When codes are labeled 'MP Criteria' the provider should submit for Recommended Clinical Review (Predetermination); this is recommended for many listed codes.
Examples: 50250, 50360, 51715 are annotated MP Criteria and reference specific medical policies.
Prior Authorization
Prior authorization note for unlisted implant/device codes
Unlisted implantable procedures may require prior authorization per contract; check member contract before proceeding (example: unlisted orbit/orbital codes).
Example: 67900 is unlisted and notes prior authorization may be required per contract.
Prior Authorization
Predetermination advised (example: 90378)
Submit Recommended Clinical Review (Predetermination) when codes are labeled 'MP Criteria'; this avoids post-service review and supports coverage decisions.
Example: 90378 is MP Criteria and has a prior authorization note.
Prior Authorization
Prior authorization may be required (90378 example)
Some services may require prior authorization per contract — review contract rules before providing treatment to prevent claim denials.
Example: 90378 includes 'Prior Authorization may be required per contract agreement.'
Prior Authorization
Predetermination for reproductive services
Reproductive tissue cryopreservation and storage codes marked 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) prior to service.
Codes include 89335, 89337, 89342, 89343, 89346, 89398 and related services.
Prior Authorization
Predetermination required for MP Criteria monitoring/cardiac codes
When codes are marked 'MP Criteria' submit for Recommended Clinical Review (Predetermination) before the service to avoid post-service review and possible denial.
Examples include monitoring and cardiac codes marked MP Criteria (e.g., 93228, 93229).
Prior Authorization
Prior authorization may be required for selected services (e.g., 99183)
Some procedure codes (e.g., certain anesthesia, monitoring, or U-codes) may require prior authorization per contract; check prior authorization requirements before scheduling.
Example: 99183 (Hyperbaric Oxygen Therapy) notes prior authorization may be required per contract.
Denial Risk
EIU entries — not reimbursed (check CPCP)
Codes flagged 'EIU' indicate the procedure/service is not reimbursed by the Plan; providers should not expect payment for these services and may face denial if billed.
Check the Clinical Payment and Coding Policy (CPCP) for EIU guidance.
Some non-covered entries include a note that prior authorization may still be required per contract — verify contract terms for member-specific requirements.
Many U-codes listed as Non Covered include 'Prior Authorization may be required per contract agreement.'
Prior Authorization
Predetermination required for T-code MP Criteria entries
Codes labeled 'MP Criteria' require submission for Recommended Clinical Review (Predetermination) prior to service to avoid post-service review and potential denial.
Examples: T-code and temporary procedure entries (0253T, 0266T, 0345T) are MP Criteria and should be submitted for predetermination.
When a code is marked 'MP Criteria' providers should submit for Recommended Clinical Review (Predetermination) to avoid post-service review.
Example codes flagged MP Criteria include 0479T and 0480T (cosmetic/laser procedures).
Note
Verify policy/effective date before billing (0651T example)
Check associated policy and effective date notes for codes added or changed (example: 0651T added effective 01/01/2023 and listed as EIU).
Code 0651T (MAG CTRLD CAPSULE ENDOSCOPY) is EIU with add effective date 01/01/2023 — verify policy before billing.
Prior Authorization
Predetermination required for MP Criteria A-code entries
Providers must submit for Recommended Clinical Review (Predetermination) when codes are annotated 'MP Criteria' to avoid post-service review; follow the referenced medical policy.
Prior authorization / predetermination recommended for select C-codes
Some codes are marked 'MP Criteria' and also note that prior authorization or predetermination is recommended per contract or referenced policy — submit accordingly.
Examples: C9257 and other C-codes list MP Criteria and note prior authorization may be required per contract.
Note
How to request Recommended Clinical Review (Predetermination)
To request a Recommended Clinical Review (Predetermination), refer to Utilization Management on the payer website or submit via Availity as instructed in the code list.
Website Utilization Management instructions and Availity submission are the designated channels.
Documentation Required
Documentation expectations for predetermination
When submitting predetermination/prior authorization, include documentation supporting that the service meets the referenced Medical Policy Criteria; unlisted procedures require detailed description and medical necessity documentation.
Provide clinical rationale and reference the linked SUR/MED policy IDs cited in the code line.
Prior Authorization
Prior authorization per contract — verify per-code notes
Prior authorization may be required per contract for certain services; verify contract-level PA requirements and follow submission channels for predetermination where MP Criteria applies.
Example: 38206 (stem cell harvest) notes prior authorization may be required per contract.
Documentation Required
Map predetermination to the referenced medical policy
Some codes are mapped to specific medical policies; when MP Criteria applies, submit predetermination referencing the mapped SUR/MED policy numbers listed with the code.
Examples: SUR703.002, SUR703.047 and others are linked to hematopoietic cell transplantation codes.
Documentation Required
Unlisted procedures — anticipate clinical review and documentation
Unlisted procedure codes may be subject to contract or clinical review and typically require predetermination and supporting documentation describing the service and medical necessity.
Examples: 49329, 49659, 49999 and many unlisted codes in the list.
Prior Authorization
Submit predetermination when MP Criteria applies (reiterated)
When MP Criteria applies, submit Recommended Clinical Review (Predetermination) prior to service; this recommendation is repeated across multiple code entries to avoid post-service denials.
Some additional MP Criteria examples include listed procedure codes across the extract; submit predetermination per the referenced policy to avoid post-service review.
Providers should reference the code line and associated policy when submitting documentation.
Note
General predetermination submission guidance
General guidance: submit for Recommended Clinical Review (Predetermination) for MP Criteria codes and follow Utilization Management/Availity channels; failure to submit may lead to post-service review or denial.
Presence on the list does not guarantee coverage — consult member benefits or customer service.
For implant or replacement procedures the code lines may indicate that prior authorization is required per contract; confirm PA requirements before performing implant/replacement services.
Examples: cochlear implant (69930) and some middle ear implant codes note prior authorization may be required.
Prior Authorization
Predetermination when MP Criteria applies
When MP Criteria applies, submit for Recommended Clinical Review (Predetermination) prior to service; this is recommended whenever the code line indicates MP Criteria.
Documentation Required
Predetermination recommended — include policy-mapped documentation
Predetermination is recommended when MP Criteria applies; providers should submit clinical documentation per the referenced medical policy to support medical necessity.
Reference the SUR/MED policy ID shown on the code line in the predetermination request.
Documentation Required
Unlisted code documentation guidance
For unlisted procedure codes include a full description of the service, operative report or procedure note, and rationale for medical necessity when submitting for predetermination or clinical review.
Unlisted codes (e.g., 67999, 66999) may be subject to contract/clinical review and require detailed supporting documentation.
Denial Risk
Failure to predetermine may lead to denial
Predetermination is recommended for MP Criteria codes; failure to submit may result in post-service review and potential denial.
Prior Authorization
Predetermination required — example codes
Certain named procedure examples in the list explicitly require predetermination; follow the code line instructions and referenced policy when submitting.
Example codes: 43236, 43633, 0253T — all annotated MP Criteria.
Documentation Required
Predetermination submission — include policy citation
When submitting predetermination, include the clinical documentation referenced in the code line and cite the applicable medical policy to expedite review.
Prior Authorization
Predetermination recommended (reiterated)
Items with 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review; this recommendation is reiterated across code lines.
Documentation Required
Predetermination and documentation when MP Criteria applies
When MP Criteria applies, providers should submit for Recommended Clinical Review (Predetermination) and provide documentation per the referenced medical policy to support medical necessity and avoid denials.
Codes such as C9257, C9739/C9740 note MP Criteria and may require predetermination/prior authorization.
Note
Presence on list does not guarantee coverage — check member benefits
Presence of a code on this list does not guarantee coverage; consult the member benefit booklet or contact customer service to confirm coverage for a specific member before billing.
Prior Authorization
Predetermination recommended (general)
Predetermination is recommended for MP Criteria codes across the list; failure to obtain predetermination may result in post-service review or denial.
Prior Authorization
Prior authorization may be required (general advisory)
Prior authorization may be required per contract for certain procedures; verify prior authorization obligations in the member's benefit plan before performing the service.
When codes are labeled 'MP Criteria' submit for Recommended Clinical Review (Predetermination) to avoid post-service review; check code notes for any simultaneous PA requirement.
Denial Risk
Non-covered procedures — will be denied if billed
Codes explicitly labeled 'Non Covered' are not covered by the Plan and are not subject to pre-service review; claims for these services will be denied.
Examples: 21248 and 21249 are listed 'Procedure/service not covered by the Plan.'
Denial Risk
EIU procedures — not reimbursed (denial risk)
Procedures marked EIU are not reimbursed by the Plan and will not be paid; do not submit expecting reimbursement unless policy changes.
Examples: 36473/36474 are EIU for endovenous mechanochemical ablation; 30468/30469 nasal valve procedures are EIU.
Denial Risk
Failure to predetermine may trigger denial
Many codes annotated 'MP Criteria' require predetermination; failure to obtain Recommended Clinical Review (Predetermination) may trigger post-service denial.
Prior Authorization
Request Recommended Clinical Review via payer channels
Recommended Clinical Review (Predetermination) should be requested through Utilization Management or Availity for codes annotated 'MP Criteria'; omission increases risk of post‑service review.
Denial Risk
Unlisted code review risk — provide full documentation
Some unlisted codes carry higher review risk and may be denied without adequate supporting documentation; include operative reports and clear descriptions when submitting.
Examples: 67900-67902, 67999 (unlisted orbit/orbital repair) are flagged Unlisted and MP Criteria.
Denial Risk
Predetermination recommended — consequences of failure to submit
When providers fail to submit predetermination for MP Criteria codes, claims may be subject to post-service review and possible denial; submit before service when possible.
Denial Risk
Unlisted procedures — review/denial risk
Unlisted procedure codes may be subject to contract/clinical review and could be denied if not supported with documentation (examples cited in the list).
Codes flagged EIU are not reimbursed by the Plan; submitting claims for EIU-coded services may result in denial and are not subject to predetermination.
Check the Clinical Payment and Coding Policy (CPCP) for EIU details.
Denial Risk
Predetermination advised — consequences of failing to submit
Providers who do not submit predetermination for MP Criteria codes risk post-service review and denial; the document repeatedly advises predetermination to avoid this outcome.
Documentation Required
Unlisted code documentation and review risk
Unlisted procedure submissions carry increased review risk; include comprehensive clinical documentation and reference the mapped medical policy when requesting predetermination.
For MP Criteria codes, predetermination is advised and providers should reference the code line and mapped policy when submitting to expedite review.
Examples: C9739/C9740 (PUL) marked MP Criteria with SUR710.023.
Denial Risk
Non-covered services — do not expect reimbursement
Non-covered codes are not benefits under the Plan; providers should not perform these expecting payment and must verify member benefits before proceeding.
Examples include many A-code and D-code non-covered entries listed in the extract.
Note
EIU guidance — consult CPCP
EIU guidance: codes labeled Experimental/Investigational/Unproven are not reimbursed and not subject to pre-service review; consult the CPCP EIU policy for details before considering these services.
Denial Risk
Non-covered/EIU codes — high denial risk
Non-covered or EIU codes present a denial risk; verify coverage and consider alternative covered options or obtain predetermination where MP Criteria applies.
Prior Authorization
MP Criteria — predetermination advised (summary)
MP Criteria codes should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review and potential denial; this is reiterated across the code list.
When a code is labeled 'MP Criteria' submit predetermination; combined with EIU or Non-Covered flags, failure to follow these instructions increases denial risk.
Denial Risk
Non-covered/EIU items — provider impact
Non-covered and EIU items are not reimbursed and will likely be denied if billed; verify member benefits and avoid performing non-covered services without prior approval or confirmation.
When codes are annotated 'MP Criteria' providers should submit for Recommended Clinical Review (Predetermination) per the referenced medical policy to avoid post-service review.
Note
Non Covered items — provider action
For non-covered items, consult member benefits and do not perform services expecting plan payment; these services are not subject to predetermination.
Note
EIU items — not reimbursed (summary)
Items marked EIU are not reimbursed; providers should not submit these expecting payment and should review CPCP EIU policy for any administrative handling guidance.
Denial Risk
Non-covered/EIU denial risk — reiterated
Non-covered and EIU codes repeatedly flagged in the list carry a high risk of denial; verify benefits and consider alternatives or obtain prior authorizations where applicable.
Predetermination is recommended in multiple entries; providers should follow Utilization Management/Availity submission instructions and include policy-referenced documentation.
Denial Risk
Predetermination recommended (reiteration)
Failure to submit Recommended Clinical Review (Predetermination) for MP Criteria codes may lead to post-service review and potential denial — submit beforehand when possible.
Examples from listDental/gum procedures (41820–41874 series) and spectacle fitting codes (92340–92370) shown as Non Covered
EIU definition
EIU (definition)Experimental, Investigational, Unproven (EIU): Procedures/services not reimbursed by the Plan and not subject to pre-service review.
Administrative noteCheck the EIU policy (CPCP) referenced in the list for additional guidance
Billing consequenceSubmitting EIU-designated services may result in denial as they are not reimbursed
EIU contextual definition
Contextual EIU noteEIU entries are marked 'Procedure/service not reimbursed by the Plan. Not subject to pre-service review.'—used where evidence is insufficient (examples: cryotherapy 17360; endovenous mech-chem codes 36473/36474)
Where to checkRefer to Clinical Payment and Coding Policy (CPCP) for EIU handling
Effect on predeterminationEIU items are not subject to predetermination; they remain administratively excluded
Unlisted procedure definition
Unlisted procedure definitionProcedure/service not specifically defined or classified; may be subject to contract/clinical review.
Provider requirementUnlisted codes may require submission of supporting documentation describing the service and medical necessity
ExamplesMany 'UNLISTED' CPT entries are flagged throughout the list (e.g., 38999, 39499, 66999)
EIU — procedure/service not reimbursed
EIU — not reimbursed (A-code example)Multiple A-code entries (A2002–A2013, A2014 etc.) are labeled EIU: 'Procedure/service not reimbursed by the Plan' for bioengineered skin/soft tissue substitutes.
MP Criteria / Recommended Clinical Review keyMP Criteria indicates the procedure is reviewed against a named Medical Policy; submit for Recommended Clinical Review (Predetermination) to avoid post-service review.
When to submitSubmit predetermination per Utilization Management instructions (payer website or Availity)
ExamplesTranscatheter mitral valve (33418), hematopoietic transplant codes (38206) are labeled MP Criteria with SUR policy cross-reference
Recommended Clinical Review (Predetermination)A recommended submission for clinical review prior to service to avoid post-service review; procedures may also require prior authorization per contract.
How to requestRefer to Utilization Management on the payer website or submit via Availity for predetermination requests
Why it's recommendedFailure to obtain predetermination for MP Criteria codes may result in post-service review and potential denial
EIU definition (alternate chunk)
EIU alternate wording'Procedure/service not reimbursed by the Plan. Not subject to pre-service review.'—used across code groups to flag investigational items.
Cross-referenceCheck the Clinical Payment and Coding Policy (CPCP) indicated in list for EIU handling
Typical usesApplied to novel tests, certain devices, and many A-/C-/T-codes listed as experimental
MP Criteria definition (alternate chunk)
MP Criteria (alternate)Procedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination) to avoid post-service review (examples: SUR707.025, SUR713.034)
Typical annotationsMP Criteria lines include referenced SUR/MED policy IDs adjacent to the CPT/HCPCS code
Provider implicationPredetermination advised; prior authorization may also be required per contract for some implantable devices
Unlisted definition (alternate chunk)
Unlisted (alternate) definitionUnlisted codes may have add/retire effective dates and can be subject to contract or clinical review when billed.
Documentation needProviders should supply detailed service description and justification when submitting unlisted codes for review
Example entriesA2014–A2017 show Add/Retire effective lines alongside Unlisted/MP entries
Unlisted procedure (additional chunk refs)
Unlisted procedure (additional)Many CPT unlisted codes (e.g., 38999, 39499, 66999) are flagged Unlisted and may require contract/clinical review.
Billing adviceCheck member contract and submit predetermination/documentation for unlisted services to reduce denial risk
Where foundUnlisted flags appear in multiple sections of the code list across specialties
EIU (alternate chunk refs)
EIU (alternate entries)A2014–A2017 and A4596 illustrate EIU lines with Add/Retire effective dates and CPCP cross-reference—procedure/service not reimbursed by the Plan.
Administrative effectCodes may flip between EIU and MP Criteria across quarters; use effective/retire dates to determine current status
Check policyRefer to the CPCP and referenced SUR policies for any nuance before billing
MP Criteria / predetermination commentary
MP Criteria commentaryMP Criteria entries map codes to named Medical Policies; the code list itself does not contain full clinical eligibility criteria—refer to referenced SUR/MED policies.
Operational notePredetermination submission is recommended to avoid post-service review for MP Criteria codes
Example policiesSUR703.002, SUR707.025, SUR716.001 commonly referenced in list excerpts
EIU — check CPCP note
EIU — CPCP cross-referenceEIU items direct providers to 'Check EIU policy' in the Clinical Payment and Coding Policy (CPCP) for specifics; EIU items are not reimbursed.
Where usedApplied across CPT, HCPCS, and A/C-code groups for investigational tests/devices/products
Provider impactDo not expect reimbursement for EIU-labeled services; verify before providing service
MP Criteria (alternate)
MP Criteria (alternate) short noteCodes such as 66179–66183 and 66989–66991 are MP Criteria and reference SUR713.034 (Aqueous Shunts and Stents for Glaucoma)
Predetermination adviceSubmit for Recommended Clinical Review per the referenced policy to avoid post-service review
Example useOphthalmology implant/drainage device codes are commonly MP Criteria in the list
Unlisted (alternate chunk refs)
Unlisted (alternate) guidanceUnlisted codes should be supported with clinical documentation; where an unlisted item is linked to a policy it may be processed under that policy's criteria.
ExamplesMany A-, B-, C-, D-codes show Unlisted flags and may require PA per contract
ActionContact Utilization Management for predetermination guidance when using unlisted codes
MP Criteria — short definition
MP Criteria — short definitionProcedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination).
PurposeIdentify services that require clinical review to determine medical necessity under referenced policies
Provider stepUse predetermination mechanisms provided by the payer to request review
EIU — CPCP cross-reference
EIU — CPCP cross-ref (alternate)EIU entries repeatedly instruct to check the Clinical Payment and Coding Policy (CPCP) for details; EIU = not reimbursed.
ImplicationProviders should not rely on predetermination to secure payment for EIU items; they remain administratively excluded
ExampleA2002–A2013 and A2014 series flagged as EIU for bioengineered skin substitutes
EIU definition (alternate)
EIU definition (alternate)'Procedure/service not reimbursed by the Plan. Not subject to pre-service review.' used to denote EIU across multiple code groups.
Examples36473/36474 (endovenous mech-chem) and 17360/17380 (cryotherapy) shown as EIU
Recommended checkRefer to CPCP08 when EIU is indicated
MP Criteria (alternate chunk refs)
MP Criteria (alternate chunk refs)MP Criteria entries include code-specific SUR/MED policy cross-references and indicate predetermination is advised (e.g., 33418 SUR707.025)
Practical effectCoverage determination is made by reviewing clinical documentation against the named Medical Policy Criteria
Where to submitUtilization Management via payer website or Availity
Non Covered (alternate chunk refs)
Non Covered (alternate) entriesSeveral codes are explicitly labeled 'Non Covered: Procedure/service not covered by the Plan. Not subject to pre-service review.'
ExamplesDental/gum codes (41820–41874) and spectacle fitting codes (92340–92370)
Billing guidanceDo not expect reimbursement; verify member benefits for exceptions
Unlisted (alternate chunk refs)
Unlisted (alternate) entriesA2014–A2017 series show Unlisted/MP/EIU toggles with effective/retire dates—unlisted items may require contract/clinical review.
DocumentationProvide clinical justification and device/product details when billing unlisted supply codes
Check effective datesUse listed effective/retire dates to determine applicable status for service dates