Submit MP Criteria codes for Recommended Clinical Review (predetermination)

Highlighted procedures/services listed as 'MP Criteria' should be submitted for Recommended Clinical Review (predetermination) to avoid post-service review; submit prior to service when possible per the file instructions.

• MP Criteria = 'Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review.'
• Examples of MP Criteria codes in the list include dermatology and related CPT codes (e.g., 11055–11057, 11200–11201, 17106–17108).

Unlisted codes may require Prior Authorization and clinical review

Certain unlisted procedure codes are identified as 'Unlisted' and may require prior authorization per the member's contract; providers should submit for Recommended Clinical Review and include clinical details to avoid post‑service review or denial.

• Examples of unlisted codes flagged in the file: 15999, 17999, 19499, 21299, 31899, 32999, 33999, 53899, 84999.
• Include operative report and clinical justification when submitting unlisted codes for clinical review.

Unlisted codes flagged for contract/clinical review — check contract for PA

Unlisted procedure codes are flagged throughout the list as potentially subject to contract/clinical review; submit documentation and obtain prior authorization per contract to avoid retrospective denial.

• The file marks many '99' unlisted codes (e.g., 22899, 31299, 92700) as 'Unlisted: may be subject to contract/clinical review. Prior Authorization may be required per contract agreement.'
• Check member contract for PA requirements and submit Recommended Clinical Review when indicated.

MP Criteria codes — submit for Recommended Clinical Review

Procedures/services labeled 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post‑service review; many surgical and dermatology codes in the list carry this designation.

• Examples of MP Criteria surgical codes in the list include gastric restrictive procedures (43771–43775, 43842–43843) and multiple dermatology procedural codes.
• Pre-service submission (predetermination) is recommended when codes are marked MP Criteria.

Prior authorization may be required for Unlisted codes — submit for review

Certain unlisted procedure codes and other 'Unlisted' entries may require prior authorization per contract; providers should submit Recommended Clinical Review and any required PA to avoid post‑service review or denial.

• Examples: 33999 and other cardiac/ventricular assist device unlisted entries are flagged as potentially requiring prior authorization.
• When an entry appears as both Unlisted and MP Criteria, include clinical detail and request predetermination.

Unlisted codes — verify PA requirements and supply clinical documentation

Unlisted codes are frequently marked throughout the list and may be subject to contract/clinical review and prior authorization; providers should check the plan/contract and submit prior authorization when indicated.

• File examples: many codes ending in '99' (eg, 38589, 38999, 39499, 53899) are described as Unlisted and possibly subject to PA.
• Providing operative reports and clinical justification with the submission is advised.

Submit MP Criteria codes (including device/procedure codes) for Recommended Clinical Review

Many listed codes are designated 'MP Criteria' and should be submitted for Recommended Clinical Review (predetermination) to avoid post‑service review; submit clinical documentation supporting medical necessity consistent with the applicable medical policy.

• Examples: bronchial thermoplasty entries (31660, 31661) and cardiac/lung device procedures are shown as MP Criteria in the list.
• Predetermination is recommended to prevent post‑payment denials.

Unlisted intestinal/abdominal codes — PA may be required

Certain unlisted procedure codes may require prior authorization per contract; submit for Recommended Clinical Review and obtain PA as indicated to avoid post‑service review or denial.

• Examples in the intestinal/abdominal code group: 43999, 44238, 44799, 44979, 45399 may be unlisted and require PA.
• Check contract terms for member-specific PA requirements before scheduling the service.

Gastric restrictive procedure codes — submit for Recommended Clinical Review

The gastric restrictive and related procedure codes shown are designated 'MP Criteria' and should be submitted for Recommended Clinical Review to avoid post‑service review.

• Examples: 43771–43775, 43842–43843 and related gastric procedure codes are listed as MP Criteria.
• Provide operative details and medical necessity rationale when requesting predetermination.

MP Criteria + Unlisted codes — pre-service Recommended Clinical Review and possible PA

Codes marked 'MP Criteria' should be submitted for Recommended Clinical Review (pre‑service submission recommended) and 'Unlisted' codes may require prior authorization per contract to avoid post‑service review or denial.

• Examples: urologic/genital procedure codes (53865, 53866, 53899, 54699) show mixed MP Criteria/Unlisted designations.
• When in doubt, submit for Recommended Clinical Review and request PA if the member's contract requires it.

PA/Recommended Clinical Review for Unlisted and select codes

Certain unlisted codes and other unspecified procedures may require prior authorization per contract; providers should submit for Recommended Clinical Review when codes are marked 'MP Criteria' or 'Unlisted' to avoid post‑service review.

• Examples: reproductive, fertility, and other specialty unlisted entries (e.g., 58999, 59897, 59898) are flagged as Unlisted and may need PA.
• Include relevant clinical documentation with the Recommended Clinical Review submission.

Unlisted codes — verify contract PA requirements and submit documentation

Unlisted procedure codes may require prior authorization per contract agreement; providers should check contract terms and submit prior authorization when required to prevent denial or retrospective review.

• Examples: nervous system and intracranial unlisted codes (eg, 59897 listed as Unlisted/MP Criteria) and many '99' codes throughout the file.
• If a code is labeled Unlisted, include operative report, indication, and justification with any PA or clinical review request.

Predetermination (Recommended Clinical Review) required for MP Criteria codes

Submit procedures/services designated 'MP Criteria' for Recommended Clinical Review (predetermination) to avoid post‑service review; failure to submit may result in retrospective review and potential denial.

• The document defines MP Criteria as 'Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.'
• Predetermination is advised where indicated in the list.

Documentation: Unlisted code review and prior authorization expectations

Unlisted procedure codes (examples: 15999, 17999, 19499, 20999, 21299, 21499) are noted as 'Unlisted' and may be subject to contract/clinical review and prior authorization; include operative report and clinical justification when submitting.

• The file explicitly marks many '99' codes as 'Unlisted: Procedure/service not specifically defined or classified, maybe subject to contract/clinical review. Prior Authorization may be required per contract agreement.'
• Providing detailed documentation reduces risk of post‑service denial.

Recommended documentation to include with Recommended Clinical Review submissions

For codes listed as 'MP Criteria' submit documentation that supports medical necessity per the applicable medical policy when requesting Recommended Clinical Review; for 'Unlisted' codes include operative report and justification as they may require clinical/contract review or prior authorization.

• Suggested documentation includes operative reports, clinical history, prior therapies, diagnostic findings, and rationale tying the service to medical necessity criteria.
• Failure to supply adequate documentation with the submission may result in post‑service review or denial.

Risk: post-service denial without Recommended Clinical Review (predetermination)

Providers who do not submit services designated 'MP Criteria' for Recommended Clinical Review (predetermination) risk post‑service review and potential denial; predetermination is recommended to avoid retrospective denials.

• The file states: 'Submit for Recommended Clinical Review (Predetermination) to avoid post-service review.'
• Post‑service submissions may be subject to retrospective review and denial if MP Criteria are not met.

EIU-designated codes are not reimbursed — billing will be denied

Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and will be denied if billed; do not expect pre‑service review for EIU-designated codes.

• Examples in the list: 17340, 20560, 20561, 83701, 83704, 83722 and many other EIU entries.
• The file notes EIU entries are 'not subject to pre-service review' and references the EIU/CPCP policy.

EIU-coded procedures — specific non‑reimbursed examples and denial risk

Codes explicitly labeled EIU in the list (eg, 31660, 31661, 36473, 36474, 95803, 95905) are identified as 'Procedure/service not reimbursed by the Plan' and present a direct denial risk if submitted for payment.

• 31660/31661 bronchial thermoplasty entries change effective 5/15/2025 to EIU—these will be non‑reimbursed after that effective date.
• Actigraphy 95803 and select neurodiagnostic codes (95905) are shown as EIU in the list.

Unlisted code review/denial risk — obtain PA and provide clinical justification

Unlisted procedure codes may be subject to contract/clinical review and prior authorization per contract; failure to obtain required prior authorization or to provide clinical documentation may trigger denial or post‑service review.

• Examples: 33999, 38589, 38999 and other '99' codes are repeatedly flagged as Unlisted and potentially actionable for PA.
• When listed as Unlisted, include detailed clinical documentation and request predetermination if the contract requires it.

Non‑covered and EIU codes — will be denied if billed

Some services and codes are explicitly marked Non Covered or EIU; billing for these codes will result in denial because they are not benefits under the Plan.

• Examples of Non Covered or EIU items: reproductive medicine storage/thawing codes (89254–89261, 89342–89356) are Non Covered; selected device/procedure codes (53451–53454, 53860) are EIU.
• Check the list for the code's Code Group designation before billing.

Step therapy: not specified in this code list

No explicit step therapy requirements are stated in this excerpt; the document does not list step therapy pathways for the included codes.

• The step therapy module in the file indicates 'No explicit step therapy requirements are stated in this excerpt.'

Monoclonal antibody (90378) — submit for Recommended Clinical Review

Palivizumab (HCPCS 90378) is listed as 'MP Criteria' — submit for Recommended Clinical Review to avoid post‑service review prior to administration when applicable.

• 90378 entry: 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post‑service review.'
• Providers should request predetermination for monoclonal antibody administration when required by the member's benefit plan.

Unlisted pathology/chemistry/lab procedures — submit clinical review/PA

For unlisted laboratory and pathology procedures (for example 84999, 88399, 88749, 89240, 89398), submit for Recommended Clinical Review and obtain prior authorization per contract as these are flagged Unlisted and may require review.

• 84999 (Unlisted chemistry), 88399 (Unlisted surgical pathology), 89398 (Unlisted reproductive medicine laboratory) are examples flagged as Unlisted.
• Include test methodology, clinical indication, and justification in the submission.

EIU designation — no pre‑service review and not reimbursed

When a code is designated EIU in the file it is not reimbursed by the Plan and not subject to pre‑service review; providers should not expect payment for services billed with EIU-designated codes.

• The file repeatedly notes: 'EIU: Procedure/service not reimbursed by the Plan. Not subject to pre‑service review. Check EIU policy (CPCP).'
• Verify EIU designations before scheduling or billing services to avoid denials.

Documentation required for MP Criteria submissions — support medical necessity

Submit MP Criteria codes with documentation supporting medical necessity per the applicable medical policy; the file instructs providers to include sufficient clinical detail to support the Requested Service during Recommended Clinical Review.

• Documentation should link the requested service to the policy's medical necessity criteria.
• Adequate documentation at predetermination reduces risk of retrospective denial.