CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

2024 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List Effective 1/1/2024

Part of a multi-part code matrix mapping CPT/HCPCS codes to plan actions: MP Criteria (submit for Recommended Clinical Review to avoid post-service review), EIU (not reimbursed; not subject to pre-service review), or Non Covered (not covered). Effective and end date ranges for code-level designations are provided in the source.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

Policy2024 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List Effective 1/1/2024

Policy CodePolicy N/A

Change TypeCode-level designations (MP Criteria / EIU / Non Covered)

Effective Date1/1/2024

Next Review Date

Key ActionFor codes labeled MP Criteria submit the procedure/service for Recommended Clinical Review to avoid post-service review; EIU and Non Covered codes are not reimbursed and not subject to pre-service review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this part lists code-level designations (MP Criteria, EIU, Non Covered) and effective date windows; no standalone policy updates were provided.

100+Codes listed in this part (approx.)

manyRequire Recommended Clinical Review (MP)

severalEIU (not reimbursed)

multipleNon Covered

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Policy Part — Purpose & Scope (code matrix)

Utilization Management Designations & Rules

Code-level utilization designations

This section defines code-level utilization designations and how procedure codes in this file are routed for utilization management. Codes in the list are assigned one of two primary branches: Medical Policy Criteria (MP Criteria) for services reviewed against Medical Policy and recommended for clinical review (predetermination) and Experimental, Investigational and Unproven (EIU) for services not reimbursed. Operator logic: where multiple entries or overlapping date windows exist, the code-level designation in the applicable date window controls. Some codes may also be classified as Non Covered or Unlisted/Undefined per the code-specific entries in Part 9.

operator: any; label: Primary designation branches; children: [ { "operator": "any", "label": "MP Criteria (Recommended Clinical Review)", "text": "Procedure/service reviewed against Medical Policy Criteria. Submit for Recommended Clinical Review (predetermination) to avoid post-service review. Highlighted procedures may also require Prior Authorization per contract." }, { "operator": "any", "label": "EIU (Not reimbursed)", "text": "Experimental, Investigational, Unproven (EIU): Procedures/services not reimbursed by the Plan. Not subject to pre-service review. See the EIU policy in the Clinical Payment and Coding Policy (CPCP) for details." } ]

Utilization Management Designations for Listed Procedures

Utilization Management designations applied to listed procedures use a three-way classification. Each listed code in the table is assigned one of: MP Criteria, EIU (not reimbursed), or Non Covered. Where multiple designations exist across different date windows for a single code, the designation effective for the claim/service date applies. Example list entries are included as illustrative leaf nodes; 'any' operator indicates that any matching criterion routes the code to that designation.

Utilization Management Designations

MP Criteria: Covered when reviewed against Medical Policy Criteria; recommended clinical review/predetermination to avoid post-service review. May require prior authorization per contract. Example codes (illustrative): 640, 797, 11055, 11056, 11057, 11200, 11201.
EIU (Experimental/Investigational/Unproven): Not reimbursed by the Plan; check applicable EIU policy. Not subject to pre-service review. Example: specific procedures designated EIU are listed in the code table (see Part 9).
Non Covered: Procedures/services not covered by the Plan. Not subject to pre-service review. Example: Non-covered G-code and M-code entries are listed in the code table and Part 9.

Many codes have effective and end dates; always check code-specific date windows in the table when determining current designation.

Coverage/Review Classification per code is determined by the code-level coverage determinations and utilization management process defined in this part and in Part 9 (Code Disposition Entries). Codes may be assigned per-code coverage mapping (MP Criteria, EIU, Non Covered, Unlisted) and routed to the appropriate utilization management process (Recommended Clinical Review, post-service review, or not reimbursed).

Operational instructions: - For billing and claims adjudication, use the code designation effective on the date of service. - Check HCPCS E-code and M-code mappings for coverage status where applicable. - Non-covered G-code and M-code entries include associated descriptors in the code table; treat as not payable per plan. - When a code appears multiple times with overlapping effective/ending dates, apply the most specific entry that matches the service date.

General utilization management process summary: codes listed as MP Criteria are subject to recommended clinical review (predetermination) to avoid post-service review and may require prior authorization depending on contract. Codes listed as EIU are not reimbursed and are not subject to pre-service review but should be validated against the EIU policy. Non Covered codes are not benefits under the plan and are not subject to pre-service review. Unlisted/Undefined codes may be subject to contract or clinical review.

Provider action callout: Submit recommended clinical review/predetermination for MP Criteria codes when required; verify contract-level prior authorization requirements; verify effective/end dates in the code table for the applicable service date.

Billing & Provider Impact — What to do

Note

Code Lists — grouped by designation

This list is the portion of the full matrix contained in this part. For a full policy look-up, consult the complete Clinical Payment and Coding Policy/CPCP. Always confirm code effective dates shown in the full code table.

OpenPayer

2024 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List Effective 1/1/2024

Policy Part — Purpose & Scope (code matrix)

Utilization Management Designations & Rules

Billing & Provider Impact — What to do

Code Lists — grouped by designation

Key terms & meanings

Operational FAQs (billing/clinical ops)

Document changes and effective dates