ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

2026 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List

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A payer-maintained list of procedure and service codes that are subject to medical policy determinations for recommended clinical review (predetermination), post-service review, are non-covered, or are considered experimental/investigational/unproven; affects providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List

Policy CodePolicy N/A

Change TypeMaterial updates to code group assignments (new MP Criteria and EIU code listings)

Effective DateJan 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSubmit codes designated 'MP Criteria' for Recommended Clinical Review (predetermination) to avoid post-service review.

SourceLink

POLICY UPDATE CHANGES

Multiple new T- and U-series codes added with Code Group assignments and effective dates through 2026.

Several codes have MP Criteria designation requiring submission for Recommended Clinical Review to avoid post-service review (examples include 0578T, 0579T, 0580T, 0584T–0586T, 0588T–0590T, etc.).

Several codes are designated EIU (not reimbursed by the Plan and not subject to pre-service review), with effective dates on or after 6/15/2026 or earlier (examples include 0577T, 0578T as EIU after 6/15/2026, 0587T after 6/15/2026, etc.).

657total codes listed on this extract/page

1/1/2026default effective date

Alacuramanaged ambulance subset

multipleEIU-designated codes

multipleMP Criteria-designated codes

12/31/2999common ending date used

Coverage Criteria and Code Group Logic

MP Criteria (Recommended Clinical Review)

Coverage actions are determined per code group labels:

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

Many ambulance and transport codes and other listed procedures are labeled MP Criteria and should be submitted for Recommended Clinical Review.

Experimental, Investigational, Unproven (EIU)

Codes labeled EIU are not reimbursed by the Plan in any situation.

EIU: Procedure/service is experimental, investigational and unproven; not reimbursed by the Plan and not subject to pre-service review. Refer to EIU policy in the Clinical Payment and Coding Policy (CPCP).

Multiple T- and U-series codes shown in this list are designated EIU; billing these codes risks denial.

Coverage group logic

Coverage grouping statements as presented in the code list excerpt:

EIU grouping: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and are not subject to pre-service review; check EIU policy within the Clinical Payment and Coding Policy (CPCP).

Examples listed in the document include multiple T/U/CPT codes designated EIU.

MP Criteria grouping: Codes labeled 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' should be submitted for Recommended Clinical Review to avoid post-service review; they are reviewed against Medical Policy Criteria and may be covered with clinical criteria.

Examples provided in the excerpt include selected T/U/CPT codes assigned MP Criteria.

Unlisted code handling: Unlisted procedure codes may be subject to contract/clinical review and Prior Authorization per contract agreement.

Unlisted examples (e.g., 15999, 19499, 22899) are identified as possibly requiring contract/clinical review and PA.

Code group coverage logic

Coverage status follows the code group label shown for each code:

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

Applies to codes labeled 'MP Criteria' (examples appear throughout the code list).

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

Applies to codes labeled 'EIU' in the list (many T/U codes).

Non Covered: Procedure/service not covered by the Plan (explicit 'Non Covered' label for specific codes).

Examples: codes explicitly marked 'Non Covered' in the extract.

Unlisted procedure codes are flagged 'Unlisted' and may be subject to contract/clinical review or prior authorization per contract.

Examples include many unlisted CPT codes shown in the document.

Coverage group criteria

Coverage determinations are assigned per-code into one of three primary groups with different operational requirements:

MP Criteria group: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

Document lists many MP Criteria codes (examples shown in the code tables).

EIU (Excluded/Not Reimbursed) group: Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; consult the EIU policy in the Clinical Payment and Coding Policy (CPCP).

Document includes many EIU-designated codes across T/U/CPT ranges.

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.

Examples of unlisted codes are provided in the extract.

Coverage categorizations and actions

Coverage categorizations and required actions by code group

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

Providers should submit clinical documentation per the Plan's Recommended Clinical Review process for MP Criteria codes.

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

Billing EIU-coded services will result in denial as not reimbursed.

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

Applies where the code is explicitly labeled 'Non Covered' in the document.

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.

Providers must verify contract requirements and submit PA when required.

Coverage by Code Group

Coverage stance is determined by code group assignment in this fragment.

MP Criteria: Codes listed as 'MP Criteria' are subject to medical policy review; submit for Recommended Clinical Review to avoid post-service review.

Examples include several T/U codes in the 0578T–0611U and other ranges.

EIU (Excluded/Not reimbursed): Codes listed as 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; billing these codes may result in denial.

Examples include multiple T-codes effective on or after indicated dates in the fragment.

Coverage group definitions

Coverage groupings assigned per code

EIU (Excluded/Not reimbursed): Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; refer to the EIU policy within the Clinical Payment and Coding Policy (CPCP).

Multiple codes in the document are explicitly designated EIU.

MP Criteria (Recommended Clinical Review): Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

Document provides MP Criteria assignments for many codes.

Unlisted procedure codes are not specifically defined and may be subject to contract/clinical review; Prior Authorization may be required per contract.

Unlisted codes are flagged throughout the extract.

Coverage group handling (EIU, MP Criteria, Unlisted)

Coverage group designations and handling instructions as stated in this segment

EIU group: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan.'

EIU-grouped codes are not subject to pre-service review; consult the CPCP for policy details.

MP Criteria: Codes labeled 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria.'

Submit for Recommended Clinical Review to avoid post-service review.

Unlisted: Codes labeled 'Unlisted: Procedure/service not specifically defined or classified, maybe subject to contract/clinical review.'

Prior Authorization may be required per contract agreement.

Plan-level code coverage groupings

Coverage stance is indicated per-code by the Plan as one of: MP Criteria (review against medical policy), EIU (not reimbursed), Non Covered, or Unlisted (may require contract/clinical review).

MP Criteria: Codes labelled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Examples in this segment include leadless pacemaker and device programming codes.

EIU (Excluded/Investigational/Unreimbursed): Codes labelled EIU are not reimbursed by the Plan and are not subject to pre-service review; see CPCP/ EIU policy.

Many diagnostic, imaging, and emerging technology codes in the segment are designated EIU.

Non Covered: Some codes are explicitly listed as Non Covered by the Plan and not subject to pre-service review.

Examples include codes explicitly labeled 'Non Covered' in the extract.

Unlisted CPT codes are identified as not specifically defined and may be subject to contract/clinical review and Prior Authorization per contract.

Providers should verify contract terms for unlisted codes (examples provided).

EIU: Not reimbursed

Coverage assignments in this document segment

EIU not reimbursed: Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review.

This segment lists multiple codes designated EIU; claims for these codes will be denied as not reimbursed.

MP Criteria: Reviewed against medical policy

Codes requiring review

MP Criteria review: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Examples in this segment include 0861T–0863T requiring submission for Recommended Clinical Review.

Unlisted: Potential contract/clinical review

Unlisted code handling

Unlisted codes: Unlisted procedure codes may be subject to contract/clinical review; prior authorization may be required per contract agreement.

Examples: 53899, 54699, 55559, 58578, 58579, 58679, 55899, 58999.

Coverage by code group

Coverage stance by code group as listed in this segment:

EIU group — Not reimbursed: Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and are not subject to pre-service review; check the EIU/CPCP policy for details.

This fragment includes many EIU-designated codes.

Unlisted codes — possible contract/clinical review: Codes labeled 'Unlisted' may be subject to contract or clinical review and Prior Authorization may be required per contract agreement.

Providers must verify contract terms before submission.

MP Criteria — Reviewed against Medical Policy Criteria: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

Submit supporting clinical documentation when requesting Recommended Clinical Review.

Per-code coverage group criteria

Coverage group rules as listed:

EIU (Excluded/Ineligible/Unreimbursed): Procedure/service not reimbursed by the Plan; Not subject to pre-service review. Check EIU policy (CPCP).

Examples include multiple Category III and other listed codes designated EIU.

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

Examples include certain implantable sensors and intravascular OCT codes explicitly marked Non Covered.

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

Examples include selected procedural and device codes designated MP Criteria.

Unlisted procedures: maybe subject to contract/clinical review; Prior Authorization may be required per contract.

Providers should verify contract terms and submit prior authorization when required.

Code Lists and Statused Code Groups

EIU / Not Reimbursed CodesCPTNot Covered

0106T	Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation.
0107T	Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation.
0108T	Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia.
0109T	Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia.
0110T	Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation.
0198T	Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report.
0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed.
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed.
0207T	Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral.
0208T	Pure tone audiometry (threshold), automated; air only.

1–10 of 121

1/13

MP Criteria / Reviewed Against Medical PolicyCPT

0175T	Computer-aided detection (CAD) with further physician review for chest radiograph(s), performed remote from primary interpretation.
0407U	Nephrology (diabetic CKD), multiplex ECLIA of sTNFR1, sTNFR2, and KIM-1 combined with clinical data, algorithm reported as risk for progressive decline in kidney function.
0585U	Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cfDNA analysis from plasma of 521 genes.
0601U	[Placeholder: code 0601U referenced in source — ensure representation].
0608U	[Placeholder: code 0608U referenced in source — ensure representation].
0611U	Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result.
0612U	Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result.
0613U	Oncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers in urine, algorithm reported as probability index for bladder cancer and upper tract urothelial carcinoma.
0628U	Nephrology (kidney disease-related genetic conditions), genomic analysis renal disease panel, saliva, DNA, NGS of 449 genes.
0630U	Oncology (breast), mRNA gene expression profiling by microarray of 80 genes, algorithm reported as molecular subtype index.

1–10 of 36

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MP Criteria: Detailed/Submit for Recommended Clinical ReviewCPT

0238T	Transluminal peripheral atherectomy; iliac artery, each vessel.
0253T	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space.
0308T	Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis.
0331T	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment.
0332T	Myocardial sympathetic innervation imaging, with tomographic SPECT.
0345T	Transcatheter mitral valve repair percutaneous approach via the coronary sinus.
0342T	Therapeutic apheresis with selective HDL delipidation and plasma reinfusion.
0483T	Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach.
0505T	Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method.
0515T	Insertion of wireless cardiac stimulator for left ventricular pacing, complete system.

1–10 of 26

1/3

Unlisted / Neutral Codes (may require contract or clinical review)mixed

15999	Unlisted procedure, excision pressure ulcer.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
19499	Unlisted procedure, breast.
20999	Unlisted procedure, musculoskeletal system, general.
21089	Unlisted maxillofacial prosthetic procedure.
21299	Unlisted craniofacial and maxillofacial procedure.
21499	Unlisted musculoskeletal procedure, head.
21899	Unlisted procedure, neck or thorax.
22999	Unlisted procedure, abdomen, musculoskeletal system.
23929	Unlisted procedure, shoulder.

1–10 of 23

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Submission, Review and Authorization Guidance

Documentation Required

Submission, Review and Authorization Guidance

Many procedure and service codes in this list are designated as Medical Policy Criteria (MP Criteria), Experimental/Investigational/Unproven (EIU), Unlisted, or Non-Covered. Action is required by providers to reduce the risk of post-service denials or claim adjustments. When a code is labeled MP Criteria, submit the procedure/service for Recommended Clinical Review (predetermination) and include supporting clinical documentation that demonstrates medical necessity. EIU-designated codes are not reimbursed and are not subject to pre-service review; billing EIU-coded services may result in claim denial. Unlisted procedure codes may require Prior Authorization per the member's contract and are often subject to contract or clinical review—verify benefit plan terms before submission.

Submit all codes designated "MP Criteria" for Recommended Clinical Review (predetermination) to avoid post-service review or denial.
Include clinical documentation (operative reports, imaging, labs, treatment history, rationale) with MP Criteria submissions to support medical necessity.
EIU-designated codes are considered experimental/investigational/unproven and are not reimbursed by the Plan; do not expect pre-service approval for EIU services.
Unlisted procedure codes (eg, 19499, 20999, 22899, 23929, 24999, 25999, 26989, 27299, 27599, 27999 series) may require Prior Authorization per contract—verify member benefits and obtain PA when required.
Some codes are managed by vendor partners (for example, certain ambulance codes managed by Alacura); follow the vendor-specific submission process when noted.
Failure to submit MP Criteria codes for Recommended Clinical Review may result in post-service clinical review and possible denial.
When submitting recommended clinical review, provide clear clinical rationale and relevant supporting records to expedite review decisions.

Key Definitions

MP Criteria definition — Procedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review

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

Operational actionSubmit clinical documentation for Recommended Clinical Review when code group = MP Criteria; predetermination recommended.

ExamplesAmbulance and related transport codes often labeled MP Criteria (managed per submission requirements).

EIU definition — Experimental, Investigational and Unproven: procedure/service not reimbursed by the Plan

DefinitionExperimental, Investigational and Unproven (EIU): procedure/service not reimbursed by the Plan and not subject to pre-service review.

Operational implicationClaims for EIU-designated codes will be denied if billed; providers should not expect pre-service predetermination to change reimbursement status.

ReferenceSee EIU policy within the Clinical Payment and Coding Policy (CPCP) for details.

MP Criteria (alternate chunk) — Procedure/service is reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review

DefinitionProcedure/service is reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

ActionSubmit clinical documentation for Recommended Clinical Review (predetermination) when codes are MP Criteria.

PurposeAvoids post-service review and potential denials; MP Criteria codes may be covered with criteria.

MP Criteria (alternate chunk) — Procedure/service not reimbursed by the Plan and not subject to pre-service review

DefinitionProcedure/service not reimbursed by the Plan and not subject to pre-service review; refer to EIU policy (CPCP).

ImplicationBilling EIU-designated codes risks denial as non-reimbursable; pre-service review is not applicable to change reimbursement status.

Where to checkConsult the EIU/Clinical Payment and Coding Policy for additional guidance and exceptions.

EIU (additional chunk) — Procedure/service not reimbursed by the Plan; not subject to pre-service review

DefinitionProcedure/service not reimbursed by the Plan; not subject to pre-service review.

Operational noteEIU-designated services will be denied if billed; providers should verify code group before submission.

Policy referenceSee Clinical Payment and Coding Policy (CPCP) for EIU details.

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

DefinitionProcedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Provider instructionPredetermination submission recommended for MP Criteria codes to prevent post-service denials.

Example codesSelected diagnostic, device, and therapeutic codes in the list are MP Criteria—submit per process.

Unlisted definition — Procedure/service not specifically defined or classified; may be subject to contract/clinical review and prior authorization per contract

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

Operational implicationProviders should verify contract terms; prior authorization may be required and clinical rationale should be submitted for review.

ExamplesMultiple CPT unlisted codes (eg, 22899, 33999, 68399) appear as Unlisted and may need contract/clinical review.

EIU (alternate) — Procedure/service not reimbursed by the Plan; not subject to pre-service review. Check the EIU/Clinical Payment and Coding Policy (CPCP).

DefinitionProcedure/service not reimbursed by the Plan; not subject to pre-service review. Check the EIU/Clinical Payment and Coding Policy (CPCP).

Operational noteEIU services are denied if billed; pre-service review is not applicable to change coverage.

GuidanceRefer to CPCP and code list for EIU effective dates and exceptions.

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

DefinitionProcedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review to avoid post-service review.

Action requiredSubmit clinical documentation to support medical necessity for MP Criteria codes.

RiskFailure to submit may result in post-service review and potential denial.

Unlisted (alternate) — Procedure/service not specifically defined or classified; may be subject to contract/clinical review. Prior Authorization may be required per contract.

DefinitionUnlisted: Procedure/service not specifically defined or classified; may be subject to contract/clinical review. Prior Authorization may be required per contract.

Provider guidanceVerify member contract and obtain Prior Authorization when required; include clinical rationale with submission.

ExamplesUnlisted CPT codes throughout the list (eg, 33999, 36299) may follow this handling.

inv-196: Non Covered — Procedure/service not covered by the Plan and not subject to pre-service review.

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

ImplicationClaims for Non Covered codes will be denied if billed; pre-service review does not apply to change coverage status.

ExamplesSpecific codes listed as Non Covered in the document (eg, 0981T, 0982T) are explicitly not a benefit.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2026 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List

Policy CodePolicy N/A

Change TypeMaterial updates to code group assignments (new MP Criteria and EIU code listings)

Effective DateJan 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSubmit codes designated 'MP Criteria' for Recommended Clinical Review (predetermination) to avoid post-service review.

SourceLink

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