Dermatology procedure and CPT code coverage list (Utilization Management — MP Criteria / Unlisted / EIU)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Oklahoma policy alerts
Know when Blue Cross Blue Shield - Oklahoma releases new policies or updates existing guidance.
Monitor payer policy activity
Lists dermatology and related procedure CPT/HCPCS codes and the payer's utilization management designation (MP Criteria, Non-Covered, EIU). Governs submission, Recommended Clinical Review (predetermination), prior authorization expectations, and coverage review for members.
No material clinical or coverage changes in this revision.
Coverage Designations and Criteria
Coverage designations (by code group)
This section summarizes coverage designations applied to procedure code groups in the policy file. Codes are categorized into four top-level coverage designations: MP Criteria (Recommended Clinical Review), Experimental/Investigational/Unproven (EIU) — Not reimbursed, Unlisted/Undefined — may require contract/clinical review (prior authorization may be required per contract), and Non Covered — not a benefit. Effective dates and ending dates are listed with each code in the master table.
CPT/HCPCS Code Tables and Examples
| 20527 | Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture). |
| 20979 | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative). |
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors, percutaneous; radiofrequency. |
| 20983 | Ablation therapy for reduction or eradication of 1 or more bone tumors, percutaneous; cryoablation. |
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service. |
| 21083 | Impression and custom preparation; palatal lift prosthesis. |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material). |
| 21121 | Genioplasty; sliding osteotomy, single piece. |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies. |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts. |
| 11920 | Tattooing, intradermal introduction of pigments to correct color defects; 6.0 sq cm or less. |
| 11921 | Tattooing; 6.1 to 20.0 sq cm. |
| 11922 | Tattooing; each additional 20.0 sq cm. |
| 11950 | Subcutaneous injection of filling material (eg, collagen); 1 cc or less. |
| 11951 | Subcutaneous injection of filling material; 1.1 to 5.0 cc. |
| 11952 | Subcutaneous injection of filling material; 5.1 to 10.0 cc. |
| 11954 | Subcutaneous injection of filling material; over 10.0 cc. |
| 11960 | Insertion of tissue expander(s) for other than breast, including subsequent expansion. |
| 11980 | Subcutaneous hormone pellet implantation. |
| 11981 | Insertion, drug-delivery implant (bioresorbable/non-biodegradable). |
Prior Authorization, Submission and Documentation Guidance
Submit MP Criteria codes for Recommended Clinical Review
Procedures and services labeled "MP Criteria" are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review (predetermination) to avoid post-service review.
Verify PA requirements for Unlisted codes
Unlisted procedure codes are not specifically defined or classified and may be subject to contract/clinical review; prior authorization may be required per contract agreement.
Prior authorization for Unlisted procedure codes
When billing an unlisted procedure code, submit prior authorization or Recommended Clinical Review as required and include supporting documentation for clinical/contract review.
Submit MP Criteria codes for clinical review
Codes designated 'MP Criteria' must be submitted for Recommended Clinical Review (predetermination) so the service can be reviewed against Medical Policy Criteria to avoid post-service review or denial.
Submit for Recommended Clinical Review (predetermination)
Many CPT and unlisted procedure codes in this list require submission for Recommended Clinical Review because they are reviewed against Medical Policy Criteria; unlisted codes may also require prior authorization per contract.
Obtain prior authorization for Unlisted codes when required
Unlisted procedure codes may require prior authorization per the member's contract; providers should verify contract terms and obtain authorization when indicated.
MP Criteria or Unlisted codes — pre-service review expected
Many listed CPT codes are designated either 'MP Criteria' or 'Unlisted' — submit for Recommended Clinical Review and/or prior authorization per contract to avoid post-service review or denial.
Check for PA on Unlisted CPTs
Unlisted CPTs are noted as 'Unlisted' and may require prior authorization per contract agreement; check the member's benefit and submit PA when indicated.
MP Criteria — submit for Recommended Clinical Review
Procedures labeled 'MP Criteria' should be submitted for Recommended Clinical Review (pre-service) to assess medical necessity against Medical Policy Criteria and avoid post-service denial.
Expect PA for some Unlisted codes
Unlisted codes may require prior authorization and clinical review per contract; submit full supporting documentation and PA when required to reduce risk of denial.
Verify contract for Unlisted code PA
Providers should verify contract-specific prior authorization requirements for Unlisted procedures; when indicated, obtain PA before performing the service.
Risk: Unlisted codes may require PA
Unlisted procedure codes are flagged as potentially subject to contract/clinical review and prior authorization; failure to obtain required PA may result in denial.
Submit PA for Unlisted procedure codes as required
Unlisted procedure codes may require prior authorization per contract; submit prior authorization or recommended clinical review as required to avoid post-service review.
MP Criteria — recommended pre-service clinical review
Codes labeled 'MP Criteria' should be submitted for Recommended Clinical Review (predetermination) to avoid post-service review; follow the medical policy submission process.
PA may be required for Unlisted and MP Criteria codes
Certain Unlisted and MP Criteria codes may require prior authorization per contract; providers should submit clinical justification and PA documentation when indicated.
Prior authorization or Recommended Clinical Review may be required
Codes designated 'Unlisted' or 'MP Criteria' may require either Prior Authorization or Recommended Clinical Review; submit the appropriate pre-service review to avoid post-service denial.
MP Criteria — submit for Recommended Clinical Review
MP Criteria codes require review against Medical Policy Criteria; submit for Recommended Clinical Review (predetermination) to avoid post-service review or denial.
Unlisted codes — possible PA and contract review
Unlisted procedure codes may be subject to contract/clinical review and may require prior authorization per contract agreement; include supporting documentation and obtain PA when indicated.
Request Recommended Clinical Review for MP Criteria codes
Many codes are labeled 'MP Criteria' and should be submitted for Recommended Clinical Review (predetermination); providers should request clinical review or PA per payer guidance before performing the service.
Documentation: Submit MP Criteria cases for Recommended Clinical Review
Submit for Recommended Clinical Review (predetermination) to avoid post-service review for procedures/services designated MP Criteria; documentation should support medical necessity per the Medical Policy Criteria.
- Provide clinical documentation demonstrating how criteria are met.
Clinical review submission — no checklist provided
No checklist is provided in this segment; when a code is labeled 'MP Criteria' submit recommended clinical review with relevant clinical records and rationale.
Submit MP Criteria codes for Recommended Clinical Review
When a code is labeled 'MP Criteria' submit for Recommended Clinical Review (predetermination) to avoid post-service review.
Document operative report and clinical rationale for Unlisted codes
For unlisted procedure codes, include operative/procedure report, clinical rationale, and any relevant prior authorization or contract references since PA and contract review may be required.
- Operative/procedure report
- Clinical rationale and indication
- Relevant contract/PA documentation
Clinical documentation requirements for MP Criteria
When submitting MP Criteria cases, provide clinical documentation that supports medical necessity and details of the procedure (donor/recipient status, autologous/allogeneic, cryopreservation, cell type) as applicable.
- Clinical rationale and history
- Procedure details (donor/recipient status, cell type)
- Operative notes and relevant imaging/labs
Include operative report and rationale for Unlisted code submissions
For unlisted procedure codes, submit operative report, clinical rationale, and any relevant contract or prior authorization documentation since prior authorization may be required per contract.
MP Criteria — submit with supporting documentation
When a code is in the 'MP Criteria' group, submit for Recommended Clinical Review to avoid post-service review; include documentation showing how the Medical Policy Criteria are met.
Documentation expectation: support medical necessity
Provide clinical documentation supporting medical necessity when submitting MP Criteria or Unlisted codes; failure to submit appropriate documentation or obtain PA may lead to post-service review or denial.
Policy Background and Scope
Background: This file is a utilization management resource that enumerates CPT and HCPCS codes and assigns each a coverage/review designation (for example, MP Criteria, Unlisted, Non Covered, or EIU) to guide provider submission practices. The list is intended to help providers determine whether to request a Recommended Clinical Review (predetermination) or obtain prior authorization to avoid post‑service denials.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.