Blue Cross Blue Shield NM non-covered codes Policy Update

Non-Covered codes — Codes listed are not covered and are not subject to pre-service review unless otherwise noted.

Procedures/services not covered by the Plan. Not subject to pre-service review. Except as otherwise noted in the date column, these codes are effective on or before January 1, 2026. Codes and descriptions listed below are representative excerpts from the Non‑Covered Code List (Fully Insured) effective 1/1/2026. Note that some codes repeat when effective/ending dates fall within the same quarter.

213AA — Proc/Treat/Equip/Ins/Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213BA — OTC Drugs Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213CA — Vision/Hear/Dental Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213EA — Assist Disabled/Misc Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213FA — Corr Eye Surgery Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213GA — Premiums Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

213HA — Copays Non-Covered. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

94453 — Oxygen titration by a health care professional with supplemental oxygen titration. Effective Date: 01/01/2013. Ending Date: 12/31/2999.

97012 — Traction, mechanical. Effective Date: 05/01/2015. Ending Date: 12/31/2999.

97014 — Electrical stimulation (unattended). Effective Date: 11/14/2012. Ending Date: 12/31/2999.

97032 — Electrical stimulation (manual), each 15 minutes. Effective Date: 11/14/2012. Ending Date: 12/31/2999.

97124 — Therapeutic procedure; massage, each 15 minutes. Effective Date: 01/01/2016. Ending Date: 12/31/2999.

97169 — Athletic training evaluation, low complexity; typically 15 minutes. Effective Date: 01/01/2017. Ending Date: 12/31/2999.

97170 — Athletic training evaluation, moderate complexity; typically 30 minutes. Effective Date: 01/01/2017. Ending Date: 12/31/2999.

99448 — Interprofessional consultative service; 21-30 minutes. Effective Date: 07/10/2015. Ending Date: 12/31/2999.

99449 — Interprofessional consultative service; 31+ minutes. Effective Date: 01/01/2021. Ending Date: 12/31/2999.

99491 — Chronic care management; physician or qualified health care professional, per calendar month. Effective Date: 01/01/2019. Ending Date: 12/31/2999.

99509 — Home visit for assistance with activities of daily living and personal care. Effective Date: 01/01/2021. Ending Date: 12/31/2999.

A0021 — Ambulance service, outside state per mile, transport (Medicaid only). Effective Date(s): 01/01/1950; 01/01/2013. Ending Date: 12/31/2999.

A0080 — Non-emergency transportation, per mile - volunteer vehicle. Effective Date(s): 01/01/1950; 01/01/2021. Ending Date: 12/31/2999.

A4490/A4495/A4500/A4510 — Surgical stockings (various lengths), each. Effective Date(s): 01/01/1950; 01/01/2022. Ending Date: 12/31/2999.

A4520 — Incontinence garment, any type, each. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

A9180 — Patient/caretaker training. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

A9270 — Non-covered item or service. Effective Date(s): 01/01/1950; 01/01/2012. Ending Date: 12/31/2999.

A9273 — Cold/hot fluid bottle, ice cap/collar, heat/cold wrap. Effective Date(s): 01/01/2011; 09/01/2020; 01/01/2021. Ending Date: 12/31/2999.

A9281 — Reaching/grabbing device, any type, each. Effective Date: 01/01/2006. Ending Date: 12/31/2999.

B4160 — Enteral feeding tube, 100 calories = 1 unit. Effective Date: 01/01/2005. Ending Date: 12/31/2999.

B4164 — Parenteral nutrition solution: carbohydrates (dextrose), homemix. Effective Date: 01/01/1950. Ending Date: 12/31/2999.

C9760/C9782/C9783/C9792/C9810 — Various investigational/IDE procedures and devices (e.g., interatrial shunt implantation, intramyocardial transplantation, coronary sinus reduction device, left atrial to coronary sinus shunt, water circulating motorized cold therapy device). Effective Dates range from 07/01/2020 to 01/01/2026. Ending Date: 12/31/2999.

D0120/D0140/D0145 — Dental evaluations and related services. Effective Date: 01/01/2013 (D0120/D0140) and entries for pediatric oral evaluation. Ending Date: 12/31/2999.

D0802/D0803/D0804 — 3D dental surface/facial scans (direct/indirect). Effective Date: 01/01/2023. Ending Date: 12/31/2999.

D1110/D1120 — Prophylaxis (adult/child). Effective Date: 01/01/2013. Ending Date: 12/31/2999.

D1206/D1208 — Topical application of fluoride (varnish/excluding varnish). Effective Date: 01/01/2013. Ending Date: 12/31/2999.

D1301 — Immunization counseling. Effective Date: 01/01/2024. Ending Date: 12/31/2999.

D1310 — Nutritional counseling for control of dental disease. Effective Date: 01/01/2013. Ending Date: 12/31/2999.

D2920-D2991 — Various restorative and crown-related dental codes (reattachment, prefabricated crowns, etc.). Effective Dates range 01/01/2013–01/01/2024. Ending Date: 12/31/2999.

D3110-D3432 — Endodontic and periradicular surgery related dental codes and associated graft/regeneration codes. Effective Dates range 01/01/2013–01/01/2014. Ending Date: 12/31/2999.

D5212-D5224 — Partial denture/prosthesis related codes; effective dates 01/01/2013–01/01/2016. Ending Date: 12/31/2999.

D6280 — Prosthesis removed and reinserted, including cleansing - per arch. Effective Date: 01/01/2026. Ending Date: 12/31/2999.

D6545-D6606 — Retainer and inlay codes. Effective Date(s): 01/01/2013–01/01/2015. Ending Date: 12/31/2999.

D9938-D9946 — Custom removable clear plastic temporary appliance placement/fabrication; occlusal guards and related services. Effective Dates: 01/01/2013–01/01/2024. Ending Date: 12/31/2999.

D9950-D9961 — Occlusion analysis, adjustments, and duplicate/copy patient's records; various effective dates with Ending Date: 12/31/2999.

G0029-G0031 — Preventive and palliative care measure codes. Effective Date: 01/01/2022. Ending Date: 12/31/2999.

G0085-G0087 — Care management home visit/oversight for Medicare CMMI models. Effective Date: 01/01/2019. Ending Date: 12/31/2999.

G0180 — Physician certification for Medicare-covered home health services (patient not present). Effective Date: 01/01/2013. Ending Date: 12/31/2999.

G0276 — Blinded procedure for lumbar stenosis (PILD) in CED clinical trial. Effective Date: 01/01/2015. Ending Date: 12/31/2999.

G0293/G0294 — Noncovered surgical/procedure anesthesia services in Medicare qualifying clinical trials. Effective Date(s): 01/01/1950; 01/01/2013. Ending Date: 12/31/2999.

G0316-G0318 — Prolonged inpatient/nursing facility/home E/M services (additional 15-minute units). Effective Date: 01/01/2023. Ending Date: 12/31/2999.

G0501 — Resource-intensive services for patients requiring specialized mobility-assistive technology during an outpatient E/M visit. Effective Date: 01/01/2017. Ending Date: 12/31/2999.

G0529/G0530 — In-home respite care and adult day center (CMMI models). Effective Date: 07/01/2024. Ending Date: 12/31/2999.

G0538 — ASCVD risk management services; clinical staff time per calendar month. Effective Date: 01/01/2025. Ending Date: 12/31/2999.

G0546-G0549/G0550 — Interprofessional assessment and management services (mental health specialty) and written report codes; Effective Date: 01/01/2025. Ending Date: 12/31/2999.

G0557/G0558 — Advanced primary care management services (complex chronic conditions), per calendar month. Effective Date: 01/01/2025. Ending Date: 12/31/2999.

G1025-G1027 — Patient-month denominators and dialysis catheter patient-month measures. Effective Date: 01/01/2022. Ending Date: 12/31/2999.

G2000-G2002 — Convulsive therapy administration in trials, post-discharge home visits (CMMI). Effective Dates: 08/01/2018–04/01/2019. Ending Date: 12/31/2999.

G2141-G2167 — Postoperative functional and pain outcome measure codes for spine procedures; Effective Date: 01/01/2020. Ending Date: 12/31/2999.

G3002 — Chronic pain management and treatment monthly bundle; required initial face-to-face visit (>=30 minutes). Effective Date: 01/01/2023. Ending Date: 12/31/2999.

Code listing — Listed codes with effective and ending dates

Code listing — Listed codes include effective and ending dates. Where multiple effective dates are shown for a single code, entries reflect historical and updated effective dates as provided in the source list.

C9810 — Water circulating motorized cold therapy device (e.g., Iceman) including all system components; Effective Date: 01/01/2026; Ending Date: 12/31/2999.

D6280 — Prosthesis removed and reinserted, including cleansing of prosthesis and abutments - per arch; Effective Date: 01/01/2026; Ending Date: 12/31/2999.

Billing/code availability — Codes and their active periods

Billing/code availability — Codes and their active periods. The list below consolidates representative codes with their active effective and ending dates as shown.

97169 — Athletic training evaluation, low complexity. Effective Date: 01/01/2017. Ending Date: 12/31/2999.

97170 — Athletic training evaluation, moderate complexity. Effective Date: 01/01/2017. Ending Date: 12/31/2999.

G0316 — Prolonged hospital inpatient/observation E/M each additional 15 minutes. Effective Date: 01/01/2023. Ending Date: 12/31/2999.

G0317 — Prolonged nursing facility E/M each additional 15 minutes. Effective Date: 01/01/2023. Ending Date: 12/31/2999.

G0318 — Prolonged home/residence E/M each additional 15 minutes. Effective Date: 01/01/2023. Ending Date: 12/31/2999.

Explicit code-level coverage notes from this segment

Explicit code-level coverage notes from this segment — Where provided, explicit billing constraints or reporting rules are preserved.

G0316/G0317/G0318 — Prolonged services: Do not report on the same date of service as other prolonged services (e.g., 99358, 99359, 99418, 99415, 99416, 99417). Do not report for any time unit less than 15 minutes.

Code listing - informational

Code listing - informational — Dental and related codes listed for informational purposes. No additional coverage rules provided in the excerpt.

D0802/D0803/D0804 — 3D dental surface/facial scans (direct/indirect). Effective Date: 01/01/2023. Ending Date: 12/31/2999.

D1110/D1120 — Prophylaxis adult/child. Effective Date: 01/01/2013. Ending Date: 12/31/2999.

D2920–D3432 — Various restorative, endodontic, and surgical dental codes with effective dates from 01/01/2013 to 01/01/2024. Ending Date: 12/31/2999.

COVERAGE CRITERIA — Code date applicability notes

COVERAGE CRITERIA — Code date applicability notes and notable service requirements extracted from the source.

G3002 — Chronic pain management and treatment monthly bundle: required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. Effective Date: 01/01/2023. Ending Date: 12/31/2999.

G0557/G0558 — Advanced primary care management services: patient consent required and must be documented; only one practitioner can furnish and be paid for the service during a calendar month; provide 24/7 access to care team; develop and maintain an electronic patient-centered comprehensive care plan. Effective Date: 01/01/2025. Ending Date: 12/31/2999.

Coverage information not included

Coverage information not included — This excerpt does not contain additional medical necessity criteria or coverage decision pathways beyond code listings and selected reporting/billing notes.

No further coverage criteria or decision-tree logic provided in the available excerpt.

CDT code effective dates (partial)

CDT code effective dates (partial) — Reference list of CDT codes with effective and ending dates as shown in the source.

D2989 — Excavation of a tooth resulting in the determination of non-restorability. Effective Date: 01/01/2024. Ending Date: 12/31/2999.

D2991 — Application of hydroxyapatite regeneration medicament - per tooth. Effective Date: 01/01/2024. Ending Date: 12/31/2999.

D9938/D9939 — Fabrication/placement of custom removable clear plastic temporary aesthetic appliance. Effective Date: 01/01/2024. Ending Date: 12/31/2999.

Informational - coding list

Informational - coding list — Additional codes are present in the source; this excerpt provides representative entries without prescribing coverage beyond the non-covered designation.

Representative codes across CPT, HCPCS, and CDT systems are listed in the full Non‑Covered Code List. Refer to the official searchable PDF for a complete listing and to confirm effective/ending dates.

Extracted coverage notes

Extracted coverage notes — Notable coverage indications and billing constraints present in the excerpt.

Prolonged E/M codes G0316, G0317, and G0318: each additional 15 minutes; do not report on same date of service as other prolonged services (99358, 99359, 99418, 99415, 99416, 99417); minimum time unit = 15 minutes.

Prolonged E/M billing rules

Prolonged E/M billing rules — Constraints and pairing rules for prolonged evaluation and management services as included in the source.

Prolonged services must be reported only in addition to appropriate primary services and must meet minimum time thresholds. They cannot be reported concurrently with specified other prolonged-service codes on the same date of service.

Interprofessional, DMHT, and Advanced Primary Care Management rules

Interprofessional, DMHT, and Advanced Primary Care Management rules — Interprofessional and DMHT services; time and reporting expectations extracted from the source.

Interprofessional consult codes (G0546–G0549/G0550) specify minute ranges (5-10, 11-20, 21-30, 31+ minutes) and require a verbal and/or written report to the treating/requesting practitioner. Effective Date: 01/01/2025. Ending Date: 12/31/2999.

G3002 chronic pain monthly bundle requires initial face-to-face visit >=30 minutes and ongoing monthly time threshold. Effective Date: 01/01/2023. Ending Date: 12/31/2999.

Advanced primary care management (G0557/G0558) includes consent, documentation, 24/7 access, continuity, care plan requirements, and limits on billing to one practitioner per month. Effective Date: 01/01/2025. Ending Date: 12/31/2999.

Listed codes and usage notes

Listed codes and usage notes — Code descriptions and usage notes included in this section (partial list).

Many codes in this list are marked non-covered. Some entries describe service definitions, time thresholds, or program-specific use (e.g., Medicare CMMI models). Consult the full non-covered file for complete context.

Coding and measurement criteria (informational)

Coding and measurement criteria (informational) — Codes describe measurable outcome thresholds, documentation requirements, and billing rules as provided in the source.

G2141–G2148 and related codes describe clinical outcome measurements (e.g., VAS pain scores, ODI functional status) with specified time windows postoperatively and improvement thresholds. Effective Date: 01/01/2020. Ending Date: 12/31/2999.

When codes reference measurement thresholds or documentation (e.g., multimodal pain management used or not used), the source lists the measure descriptions; these are informational within the non-covered listing.

Provider Actions, Notices, and Billing Guidance

Note

Non-covered services — no pre-service review required

Procedures and services listed in this document are not covered by the Plan and are not subject to pre-service review.

Billing Rule

Code listing — informational (no auth guidance)

This section presents CPT/HCPCS code entries with Effective Date and Ending Date values for provider billing reference; no prior authorization, denial risk, documentation, billing rule, or step therapy instructions are specified in this fragment.

Billing Rule

Reproductive procedure codes — date listings

Reproductive and fertility-related CPT codes (including cryopreservation and assisted fertilization codes) are listed with their Effective Date and Ending Date values for reference; no authorization instructions are provided here.

Examples include cryopreservation codes 89257–89261 and assisted fertilization codes 89280–89281 with Ending Date = 12/31/2999.

Billing Rule

Vaccine/biologic codes — informational listing

Vaccine and immune globulin HCPCS codes are listed with Effective Date and Ending Date entries for billing reference; the fragment does not include prior authorization or documentation requirements.

Examples include 90287–90288, 90393, 90476–90477, 90584, and 90589.

Billing Rule

Vision / orthoptic codes — billing reference

Vision and orthoptic fitting/repair procedure codes are listed with Effective and Ending Dates for provider billing; no pre-service or documentation instructions are included in this excerpt.

Examples include 92065 and 92340–92342, 92354–92355.

Documentation Required

Code list — no authorization guidance in this segment

This fragment is a code list showing Effective Date and Ending Date values; it contains no prior authorization instructions or denial-risk guidance.

Billing Rule

Code listing — billing reference

CPT/HCPCS codes in this section are provided as billing reference with Effective Date and Ending Date values; use the listed dates when submitting claims.

Documentation Required

Investigational device procedures — IDE study entries

Codes flagged for investigational device exemption (IDE) studies are listed to indicate they are performed only in approved IDE studies; these entries are informational and reference investigational study status.

Examples include C9760 and C9782 described as performed in an approved IDE study.

Documentation Required

Qualifying non-opioid medical device — C9810 note

C9810 is identified as a water-circulating motorized cold therapy device and is noted as a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023.

C9810 Effective Date = 1/1/2026; Ending Date = 12/31/2999.

Billing Rule

Selected HCPCS C‑codes — informational

Selected HCPCS C‑codes are listed with descriptions and Effective/Ending Dates for reference; entries note investigational study context where applicable.

Examples: C9783, C9792, C9810 (with associated IDE or qualifying-device notes).

Documentation Required

Dental procedure (D‑codes) — date listings

Dental D‑codes are enumerated with Effective Date and Ending Date values for billing reference; this fragment does not specify prior authorization or documentation requirements.

Examples include D0272–D0364 and other D‑codes with Ending Date = 12/31/2999.

Documentation Required

CDT code listings — partial billing reference

CDT dental procedure codes are listed with Effective and Ending Dates for provider billing; no prior authorization rules are shown in this excerpt.

Providers should reference these CDT entries when submitting dental claims.

Documentation Required

CDT codes — excerpt (informational)

This CDT excerpt lists procedure codes and their Effective/Ending Dates; providers should reference the code and date when billing but no authorization instructions are included here.

Billing Rule

CDT code listing — partial

Partial CDT code listings with Effective and Ending Dates are provided for billing reference; use the listed Effective Dates when determining code applicability.

Documentation Required

Code listing — no authorization instructions

ADA/CPT code entries are provided with Effective and Ending Dates; this segment contains code listings only and does not include prior authorization instructions.

Documentation Required

Coverage‑with‑evidence‑development code — G0276

G0276 is listed as a coverage‑with‑evidence‑development (CED) code for blinded percutaneous image‑guided lumbar decompression (PILD) or placebo control when performed in an approved CED clinical trial (Effective Date = 1/1/2015).

Billing Rule

Prolonged E/M services — G0316–G0318 reporting rules

Prolonged E/M G‑codes (G0316–G0318) are reported in 15‑minute increments only, must be listed separately in addition to specified primary E/M CPT codes, and must not be reported with certain other prolonged service codes.

G0316: list with inpatient/observation E/M CPTs (e.g., 99223/99233/99236); do not report with 99358, 99359, 99418, 99415, 99416.
Minimum unit for G0316–G0318 is 15 minutes.

Billing Rule

CMMI model service codes — G0529/G0530

CMMI model G‑codes for in‑home respite care and adult day center units (e.g., G0529, G0530) are effective 7/1/2024 and are designated for use in specified CMMI models.

G0529 (in‑home respite care, 4‑hour unit) and G0530 (adult day center, 8‑hour unit) effective 7/1/2024.

Billing Rule

Interprofessional mental health consults — G0546–G0551

Interprofessional mental health consult G‑codes (G0546–G0551) are time‑based consultative services that require a verbal and written report to the treating/requesting practitioner.

Examples: G0546 (5–10 minutes), G0547 (11–20 minutes), G0548 (21–30 minutes), G0549 (31+ minutes).
Effective Date = 1/1/2025 for these entries.

Billing Rule

DMHT and advanced primary care management — G0553–G0558 requirements

Digital mental health treatment (DMHT) management (G0553/G0554) and advanced primary care management codes (G0556–G0558) are listed with monthly time‑based and programmatic requirements.

G0553: first 20 minutes monthly; requires ≥1 interactive communication with patient/caregiver per month.
G0554: each additional 20 minutes monthly.
G0556–G0558: require documented patient consent, 24/7 access, continuity, comprehensive care plan, and that only one practitioner is paid per month.

Documentation Required

Advanced primary care management — G0557 (non‑Medicare-specific)

Advanced primary care management services (G0557) for patients with multiple chronic conditions require documented consent, 24/7 access, continuity of care, comprehensive care planning (electronic patient‑centered care plan), initiation rules for new or re‑establishing patients, and other specified elements.

G0557 Effective Date = 1/1/2025; Ending Date = 12/31/2999.

Documentation Required

Advanced primary care management — G0558 (Medicare‑qualified beneficiary)

G0558 describes advanced primary care management for a qualified Medicare beneficiary with multiple chronic conditions and includes the same consent, initiation, 24/7 access, continuity, comprehensive care plan, and documentation requirements.

G0558 Effective Date = 1/1/2025; Ending Date = 12/31/2999.

Billing Rule

Chronic pain management bundle — G3002 and add‑on G3003

G3002 (chronic pain management monthly bundle) requires an initial face‑to‑face visit of at least 30 minutes provided by a physician or other qualified health professional in the calendar month; G3003 is billed separately for each additional 15 minutes.

G3002: required initial face‑to‑face ≥30 minutes (first 30 minutes personally provided by physician or qualified professional).
G3003: each additional 15 minutes, listed separately in addition to G3002; minimum 15 minutes per unit.

Billing Rule

OUD demonstration — all‑inclusive payment (G2172)

G2172 is an all‑inclusive payment code for services related to highly coordinated and integrated opioid use disorder (OUD) treatment furnished for the demonstration project.

G2172 Effective Date = 4/1/2021; Ending Date = 12/31/2999.

D0171	re-evaluation ? post-operative office visit
D0180	comprehensive periodontal evaluation - new or established patient
D0190	screening of a patient
D0191	assessment of a patient
D0210	intraoral - comprehensive series of radiographic images
D0220	intraoral - periapical first radiographic image
D0230	intraoral - periapical each additional radiographic image
D0240	intraoral - occlusal radiographic image
D0250	extraoral - first radiographic image
D0270	bitewing - single radiographic image

D2710	crown - resin-based composite (indirect)
D2712	crown - ¾ resin-based composite (indirect)
D2720	crown - resin with high noble metal
D2721	crown - resin with predominantly base metal
D2722	crown - resin with noble metal
D2740	crown - porcelain/ceramic
D2750	crown - porcelain fused to high noble metal
D2751	crown - porcelain fused to predominantly base metal
D2752	crown - porcelain fused to noble metal
D2753	crown - porcelain fused to titanium and titanium alloys

OpenPayer

Non-Covered CPT/HCPCS/Category III Code List (Fully Insured)

Non‑Covered and Code Listing — Coverage Criteria

Code Tables and Key Coding Details

Provider Actions, Notices, and Billing Guidance

Dates, Code Terms, and Abbreviations