Blue Cross Blue Shield OK Plastic/Reconstructive Coverage

Coverage criteria and designations

Coverage Categories

Coverage categorization applied per procedure code group.

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

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

EIU: Experimental, Investigational, Unproven: Procedures/services not reimbursed by the Plan. Not subject to pre-service review (see EIU policy in Clinical Payment and Coding Policy).

Per-code review classification

Coverage/review determination is applied on a per-code basis as indicated below.

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

EIU - Not reimbursed: Codes marked 'EIU' are procedure/services not reimbursed by the Plan and are not subject to pre-service review; refer to the EIU/CPCP policy.

MP Criteria — submit for recommended clinical review

General processing rule for listed procedures.

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

EIU / Not reimbursed

EIU (Experimental/Investigational/Unreimbursed) entries.

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

Recommended Clinical Review / Medical Policy Criteria

Covered when reviewed and meets Medical Policy Criteria.

Required submission: Submit for Recommended Clinical Review (predetermination); the procedure/service will be reviewed against Medical Policy Criteria to determine coverage and avoid post-service review.

Utilization designations (MP Criteria vs EIU)

Coverage and review rules by designation.

MP Criteria requirement: Services listed as 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

EIU not reimbursed: Services listed as '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).

Code-level coverage designations

Coverage/designation per CPT code as listed in the Utilization Management Process excerpt.

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

EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review; check EIU policy in CPCP.

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

Coverage designations and review workflow

Coverage and review designations shown in this document segment.

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

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

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

Utilization Management Designations (MP Criteria / EIU / Non Covered)

Coverage and review stance by designation.

MP Criteria: Services labeled 'MP Criteria' require review against Medical Policy Criteria; providers should submit for Recommended Clinical Review to avoid post-service review.

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

Non Covered: Some services are explicitly 'Non Covered' and not reimbursed; not subject to pre-service review.

Per-code coverage designations

Coverage stance is assigned at the code level with one of these labels:

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

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

EIU: Procedure/service not reimbursed by the Plan; see EIU policy (CPCP).

Coverage designations

Coverage designations provided per code.

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

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

Coverage designations

Coverage determination depends on the listed designation for each code.

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

EIU (Excluded): Procedure/service not reimbursed by the Plan; not subject to pre-service review — refer to EIU policy in CPCP.

MP Criteria (review required)

Codes flagged 'MP Criteria' — submit for Recommended Clinical Review.

MP Criteria requirement: Procedure/service is reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review (predetermination) to avoid post-service review.

MP Criteria vs EIU coverage designations

Coverage and review designations shown per code:

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

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

Per-code coverage designations

Coverage designations in this segment are per-code and include MP Criteria (requires review), EIU (not reimbursed), and Non Covered.

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

Utilization designations (MP Criteria | EIU | Non Covered)

Designation-based coverage expectations in these chunks.

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

EIU: Procedure/service not reimbursed by the Plan; not subject to pre-service review.

Non Covered: Procedure/service not covered by the Plan (example: certain specific T/U codes may be labeled Non Covered).

The policy assigns certain plastic/reconstructive procedure codes a Non Covered designation, meaning the procedure/service is not covered by the Plan and is not subject to pre‑service review. Examples in this document include several cervicoplasty/blepharoplasty codes such as 15820–15823 and 15825, each shown with the explicit label "Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review." Providers should not expect reimbursement for services billed with these codes when they are labeled Non Covered in the listing.

Codes designated EIU (Experimental, Investigational, Unproven) are explicitly labeled in the list as "Procedure/service not reimbursed by the Plan. Not subject to pre‑service review." The document gives examples such as 30468 and 30469 (nasal valve repair) and several device/implant entries (eg, portions of the 3327x series), and instructs providers to check the EIU policy in the Clinical Payment and Coding Policy (CPCP) for more detail. Submission of prior authorization for an EIU‑designated code will not change reimbursement status.

The policy explains that procedures/services flagged as EIU are excluded from reimbursement—i.e., not reimbursed by the Plan—and therefore are not subject to pre‑service review. The listing emphasizes that EIU codes should be reviewed against the employer’s CPCP EIU guidance and that claims for EIU‑designated services will not be paid when billed under the labels shown in the code list.

The code list includes numerous examples where entries are labeled EIU or Non Covered. For instance, the nasal valve repair codes 30468/30469 are shown as EIU, and several newer technology T/U/U‑codes (eg, some genomic and implant codes) are annotated as either MP Criteria or EIU depending on effective date ranges. These per‑code labels indicate how the Plan will treat those services for reimbursement and review.

When a code is marked EIU the document reiterates that the service is not reimbursed by the Plan and is not subject to pre‑service review; it references the EIU policy in the Clinical Payment and Coding Policy (CPCP) for the policy rationale and details. In contrast, codes labeled MP Criteria should be submitted for Recommended Clinical Review (predetermination) to avoid post‑service review.

Multiple CPT/HCPCS codes in the listing are explicitly designated Non Covered; those entries display the plan language "Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review." Examples span specialties and include codes such as 54440, 55400, and the HCPCS example 0421U shown elsewhere in the list.

The key operational distinction in the list is between entries labeled MP Criteria and those labeled EIU/Non Covered. MP Criteria entries are reviewed against Medical Policy Criteria and providers are advised to submit for Recommended Clinical Review to avoid post‑service review. By contrast, services labeled EIU or Non Covered are shown as not reimbursed and not subject to pre‑service review; billing such codes may result in denial.

The document consistently marks specific codes with either EIU or Non Covered designations and states those codes are not reimbursed by the Plan. When codes carry these labels in the listing, the Plan’s position is that claims for those services are not payable and prior authorization does not apply to alter that status.

A number of assisted reproduction and fertility‑related services are listed as Non Covered. The listing identifies services such as culture, insemination, cryopreservation, storage, thawing, embryo biopsy and related laboratory procedures (multiple 89xxx series codes) with the explicit label "Non Covered: Procedure/service not covered by the Plan." Providers should note these assisted reproduction codes are not eligible for reimbursement under the Plan when shown as Non Covered.

In summary, entries marked EIU are treated as excluded from payment by the Plan—procedures/services not reimbursed by the Plan—and entries marked Non Covered are explicitly not covered. Providers should review the code list carefully: EIU and Non Covered labels indicate no reimbursement; MP Criteria labels indicate submission for Recommended Clinical Review is required to determine coverage.

The policy cross‑references the EIU designation to the Clinical Payment and Coding Policy (CPCP). For codes flagged EIU the listing instructs reviewers and providers to "Check EIU policy (Clinical Payment and Coding Policy)" to understand the Plan’s rationale and any supporting documentation used to determine the exclusion from reimbursement.

The listing contains numerous concrete Non Covered code examples across service categories. Sample non‑covered entries include physical modality and therapy codes such as 97012, 97014, 97032, and therapeutic massage 97124, each annotated with the plan language "Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review."

The document explicitly defines EIU as "Procedure/service not reimbursed by the Plan. Not subject to pre‑service review." That policy reference appears repeatedly next to EIU‑labeled codes and the instructions advise checking the CPCP EIU guidance for details.

Many procedures across the T/U and U‑code listings are designated EIU in the list; the policy marks these as not reimbursed. The document shows multiple novel technology or laboratory codes (for example, some 03xx/04xx U/T codes) where the Plan has applied the EIU label for the listed effective periods.

The policy restates that an EIU designation effectively means the Plan will not reimburse the service and such codes are not subject to pre‑service review. The listing warns that billing EIU‑labeled codes will result in denial consistent with the Plan’s EIU stance.

A specific Non Covered example called out in the list is 0547T ("Bone‑material quality testing by microindentation(s) of the tibia(s), results reported as a score"). The entry shows "Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review."

The code 17340 (cryotherapy for acne) is shown in the listing with the label EIU: "Procedure/service not reimbursed by the Plan. Not subject to pre‑service review." and its effective dates are indicated in the entry.

Throughout the document the EIU designation implies the Plan will not reimburse the service; the listing language equates EIU with services that are not reimbursed by the Plan and therefore are effectively considered not medically necessary for payment purposes under the Plan’s policies.

The listing provides many specific examples of procedures labeled EIU—for instance, portions of the venous ablation and endovenous therapy codes (eg, 36473 in earlier date ranges), several device implantation/removal entries, and certain laboratory/genetic test codes are annotated EIU. Each entry that is EIU includes the Plan’s EIU language and directs users to the CPCP for policy details.

The policy warns that services labeled Non Covered or EIU are triggers for denial when submitted for coverage. In operational terms, claims for codes designated Non Covered or EIU in this list are at risk for denial because the Plan has explicitly assigned a non‑reimbursable status to those codes.

Because the EIU label is applied directly in the code list, the document indicates that EIU‑labeled codes are effectively not reimbursed by the Plan for the periods shown. The listing reminds providers that EIU codes are not subject to pre‑service review and that prior authorization will not change reimbursement status.

The listing includes other specific Non Covered examples such as 0421U (oncology colorectal screening RNA/fecal hemoglobin test) which is called out in the table as "Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review." These explicit Non Covered entries should be used by billing staff to identify services that will not be paid.

Procedure and billing codes

Mixed procedure codes (examples)CPT

11201	Removal of epidermal inclusion cyst; single lesion
11719	Trimming of nondystrophic nails, any number
11920	Removal of tissue expander/implant, initial insertion (adjacent to other codes)
11921	Removal of tissue expander/implant, each additional
11922	Removal with replacement of tissue expander/implant
11951	Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11952	Subcutaneous injection of filling material; 1.1 to 5.0 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

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Skin substitute / wound careCPT

15271	Application of skin substitute graft to trunk/arms/legs; first 25 sq cm or less
15272	Application of skin substitute graft; each additional 25 sq cm
15273	Application of skin substitute graft to trunk/arms/legs; first 100 sq cm (>=100)
15274	Application of skin substitute graft; each additional 100 sq cm

Cosmetic / Plastic Surgery (MP Criteria)CPTCovered

15271	Application of skin substitute graft to trunk/arms/legs; first 25 sq cm or less
15272	Application of skin substitute graft; each additional 25 sq cm
15775	Punch graft for hair transplant; 1 to 15 punch grafts
15780	Punch graft for hair transplant; more than 15 punch grafts (dermabrasion alternatives)
15781	Dermabrasion; segmental, face
15782	Dermabrasion; regional, other than face
15783	Dermabrasion; superficial, any site
15828	Rhytidectomy; cheek, chin, and neck (Cervicoplasty mapping)
15829	Rhytidectomy; SMAS flap
15830	Excision, excessive skin/subcutaneous tissue; abdomen (panniculectomy)

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Breast surgery and reconstruction (MP Criteria)CPTCovered

19300	Mastectomy for gynecomastia
19303	Mastectomy, simple, complete
19325	Breast augmentation with implant
19328	Removal of intact breast implant
19340	Insertion of breast implant on same day of mastectomy (immediate)
19342	Insertion or replacement of breast implant on separate day from mastectomy
19350	Nipple/areola reconstruction
19355	Correction of inverted nipples
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s)
19370	Revision of peri-implant capsule, breast

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Injectables / Fillers (MP Criteria)CPTCovered

11951	Subcutaneous injection of filling material; 1 cc or less
11952	Subcutaneous injection of filling material; 1.1 to 5.0 cc
11954	Subcutaneous injection of filling material; over 10.0 cc

Wound / Soft tissue procedures (MP Criteria)CPTCovered

20527	Injection, enzyme (eg, collagenase), palmar fascial cord (Dupuytren's)
20560	Needle insertion(s) without injection(s); 1 or 2 muscles (EIU noted historically)
20979	Low intensity ultrasound stimulation to aid bone healing
20982	Percutaneous ablation therapy for bone tumor; radiofrequency
20983	Percutaneous ablation therapy for bone tumor; cryoablation

Craniofacial / Maxillofacial (MP Criteria)CPTCovered

21073	Manipulation of TMJ requiring anesthesia
21083	Impression and custom preparation; palatal lift prosthesis
21120	Genioplasty; augmentation
21121	Genioplasty; sliding osteotomy, single piece
21122	Genioplasty; sliding osteotomies, 2 or more
21123	Genioplasty; sliding, augmentation with interpositional bone grafts
21244	Reconstruction of mandible, extraoral, with transosteal bone plate
21245	Reconstruction of mandible or maxilla, subperiosteal implant; partial
21246	Reconstruction of mandible or maxilla, subperiosteal implant; complete
21247	Reconstruction of mandibular condyle with autografts

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Orthopedic / Spine / Joint (MP Criteria / EIU mix)CPT

21685	Hyoid myotomy and suspension
21740	Reconstructive repair of pectus excavatum or carinatum; open
21742	Reconstructive repair of pectus excavatum; minimally invasive, without thoracoscopy
21743	Reconstructive repair of pectus excavatum; minimally invasive, with thoracoscopy
22505	Manipulation of spine requiring anesthesia, any region
22526	Percutaneous intradiscal electrothermal annuloplasty; single level (EIU)
22527	Percutaneous intradiscal electrothermal annuloplasty; additional levels (EIU)
22586	Arthrodesis, pre-sacral interbody technique L5-S1 (EIU)
22868	Insertion of interlaminar/interspinous device; second level (EIU)
22869	Insertion of interlaminar/interspinous device; single level (EIU)

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Vascular / Endovascular (MP Criteria)CPTCovered

36474	Endovenous ablation therapy; subsequent vein(s) treated (mechanochemical)
36475	Endovenous ablation therapy, radiofrequency; first vein treated
36476	Endovenous ablation therapy, radiofrequency; subsequent vein(s)
36478	Endovenous ablation therapy, laser; first vein treated
36479	Endovenous ablation therapy, laser; subsequent vein(s)
36482	Endovenous ablation by chemical adhesive; first vein treated
36483	Endovenous ablation by chemical adhesive; subsequent vein(s)
37215	Transcatheter stent, cervical carotid artery with distal embolic protection
37216	Transcatheter stent, cervical carotid artery without distal embolic protection
37217	Transcatheter stent, intrathoracic common carotid/innominate by retrograde treatment

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Cardiac / Devices (MP Criteria)CPTCovered

33211	Insertion or replacement of temporary transvenous dual chamber pacing electrodes
33213	Insertion of pacemaker pulse generator only; with existing dual leads
33225	Insertion of LV pacing electrode (cardiac venous system) at time of generator insertion
33267	Exclusion of left atrial appendage, open
33268	Exclusion of left atrial appendage, open, performed at time of other sternotomy
33269	Exclusion of left atrial appendage, thoracoscopic
33270	Insertion or replacement of permanent subcutaneous implantable defibrillator
33274	Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular
33275	Transcatheter removal of permanent leadless pacemaker, right ventricular
33276	Insertion of phrenic nerve stimulator system

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Transcatheter Valves / Thoracic (MP Criteria)CPTCovered

33340	Percutaneous transcatheter closure of left atrial appendage with endocardial implant
33361	TAVR percutaneous femoral approach
33362	TAVR open femoral artery approach
33363	TAVR open axillary approach
33364	TAVR open iliac artery approach
33365	TAVR transaortic approach
33366	TAVR transapical exposure
33367	Cardiopulmonary bypass support with percutaneous cannulation for TAVR (add-on)
33368	Cardiopulmonary bypass support with open peripheral cannulation for TAVR (add-on)
33369	Cardiopulmonary bypass support with central cannulation for TAVR (add-on)

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Ventricular assist / ECMO (MP Criteria)CPTCovered

33542	Transcatheter pulmonary valve implantation (mapping entry)
33880	Endovascular repair of descending thoracic aorta; coverage of left subclavian origin
33881	Endovascular repair not involving coverage of left subclavian origin
33883	Placement of proximal extension prosthesis; initial extension
33884	Placement of proximal extension prosthesis; additional extension
33886	Placement of distal extension prosthesis(s) delayed after repair
33889	Open subclavian to carotid transposition with endovascular repair
33927	Implantation of a total replacement heart system (artificial heart)
33928	Removal and replacement of total replacement heart system
33929	Removal of total replacement heart system for heart transplantation (add-on)

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Endovascular / Interventional (MP Criteria)CPTCovered

36474	Endovenous ablation therapy of incompetent vein; subsequent vein(s) - mechanochemical
36475	Endovenous ablation therapy, percutaneous, radiofrequency; first vein
36476	Endovenous ablation therapy, percutaneous, radiofrequency; subsequent
37215	Transcatheter placement of intravascular stent(s), cervical carotid, with distal embolic protection
37216	Transcatheter placement of intravascular stent(s), cervical carotid, without distal embolic protection
37241	Vascular embolization or occlusion; venous
37242	Vascular embolization or occlusion; arterial
37243	Vascular embolization or occlusion; for tumors/organ ischemia
37244	Vascular embolization or occlusion; for hemorrhage

Diagnostic / Lab / Molecular (MP Criteria)mixedCovered

81161	DMD deletion/duplication analysis
81206	BCR/ABL1 major breakpoint analysis
81207	BCR/ABL1 minor breakpoint analysis
81241	F5 Leiden variant analysis
81243	FMR1 fragile X evaluation
81420	Cell-free fetal DNA aneuploidy panel (13,18,21)
81457	Solid organ neoplasm genomic panel - MSI
81458	Solid organ neoplasm genomic panel - CNV/MSI
81459	Solid organ neoplasm genomic panel - comprehensive
81462	Cell-free nucleic acid genomic panel

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Miscellaneous (MP Criteria)CPTCovered

66561	(placeholder)
79445	Radiopharmaceutical therapy, intra-arterial particulate administration
96547	HIPEC; first 60 minutes (add-on)
96548	HIPEC; each additional 30 minutes (add-on)

Therapy / Rehabilitation (MP Criteria)CPTCovered

97605	Negative pressure wound therapy; total wound surface area <= 50 sq cm
97606	Negative pressure wound therapy; total wound surface area > 50 sq cm
97607	Negative pressure wound therapy using disposable non-durable equipment; <=50 sq cm
97608	Negative pressure wound therapy using disposable non-durable equipment; >50 sq cm
97813	Acupuncture with electrical stimulation (initial 15 minutes)
97814	Acupuncture with electrical stimulation; each additional 15 minutes

Selected CPT Codes (excerpt)CPTCovered

15828	Rhytidectomy; cheek, chin, and neck
15829	Rhytidectomy; SMAS flap
15830	Excision, excessive skin/subcutaneous tissue; abdomen
15832	Excision, excessive skin/subcutaneous tissue; thigh
15833	Excision, excessive skin/subcutaneous tissue; leg
15834	Excision, excessive skin/subcutaneous tissue; hip
15835	Excision, excessive skin/subcutaneous tissue; buttock
15836	Excision, excessive skin/subcutaneous tissue; arm
15837	Excision, excessive skin/subcutaneous tissue; forearm or hand
15838	Excision, excessive skin/subcutaneous tissue; submental fat pad

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Additional CPT Codes (excerpt)CPTCovered

17106	Destruction of cutaneous vascular proliferative lesions; <10 sq cm
17107	Destruction of cutaneous vascular proliferative lesions; 10-50 sq cm
17108	Destruction of cutaneous vascular proliferative lesions; >50 sq cm
17340	Cryotherapy for acne (EIU)
17360	Chemical exfoliation for acne
17380	Electrolysis epilation, each 30 minutes

Breast & Soft Tissue (continued)CPTCovered

19105	Ablation, cryosurgical, of fibroadenoma, each fibroadenoma
19300	Mastectomy for gynecomastia
19303	Mastectomy, simple, complete
19325	Breast augmentation with implant
19328	Removal of intact breast implant
19340	Removal of ruptured breast implant = immediate insertion mapping

Plastic / Reconstructive (misc)CPTCovered

19499	Unlisted procedure, breast
20527	Injection, enzyme (eg, collagenase), palmar fascial cord
20560	Needle insertion(s) without injection(s); 1 or 2 muscles (EIU)

Cardiac (selected)CPTCovered

33211	Insertion or replacement of temporary transvenous dual chamber pacing electrodes
33213	Insertion of pacemaker pulse generator only; with existing dual leads
33361	TAVR percutaneous femoral approach
33362	TAVR open femoral approach

Vascular / Endovascular (selected)CPTCovered

33880	Endovascular repair of descending thoracic aorta; coverage of left subclavian
33881	Endovascular repair of descending thoracic aorta; not involving coverage
33883	Placement of proximal extension prosthesis, initial
33884	Placement of proximal extension prosthesis, additional

VAD / Transplant (selected)CPTCovered

33975	Insertion of ventricular assist device; extracorporeal, single ventricle
33976	Insertion of ventricular assist device; extracorporeal, biventricular
33979	Insertion of implantable intracorporeal VAD, single ventricle

Pulmonary / Thoracic (selected)CPTCovered

32553	Placement of interstitial device(s) for radiation therapy guidance; percutaneous intra-thoracic
32664	Thoracoscopy with thoracic sympathectomy
32994	Percutaneous cryoablation of pulmonary tumor(s)
32998	Percutaneous radiofrequency ablation of pulmonary tumor(s)

Bronchoscopy (selected)CPTCovered

31647	Bronchoscopy with insertion of bronchial valve(s), initial lobe
31648	Bronchoscopy with removal of bronchial valve(s), initial lobe
31649	Removal, each additional lobe
31651	Insertion, each additional lobe

Sleep / Neuro (selected)CPTCovered

91117	Colon motility study, minimum 6 hours recording
95783	Polysomnography; younger than 6 years, with CPAP initiation
95807	Sleep study, ventilation/respiration monitoring attended
95810	Polysomnography; age 6+, sleep staging with 4+ parameters

Breast surgery and reconstruction CPT CodesCPTCovered

19300	Mastectomy for gynecomastia
19303	Mastectomy, simple, complete
19325	Breast augmentation with implant
19328	Removal of intact breast implant
19340	Insertion of breast implant on same day of mastectomy (immediate)
19342	Insertion or replacement of breast implant on separate day from mastectomy
19350	Nipple/areola reconstruction
19355	Correction of inverted nipples
19357	Tissue expander placement in breast reconstruction, including subsequent expansions
19370	Revision of peri-implant capsule, breast

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Misc reconstructive/therapeutic CPT CodesCPTCovered

20527	Injection, enzyme (eg, collagenase), palmar fascial cord (Dupuytren's)
20560	Needle insertion(s) without injection(s); 1 or 2 muscles (EIU)
20979	Low intensity ultrasound stimulation to aid bone healing
21073	Manipulation of TMJ requiring anesthesia
21083	Palatal lift prosthesis preparation

Craniofacial / Mandible ReconstructionCPTCovered

21120	Genioplasty; augmentation
21121	Genioplasty; sliding osteotomy, single piece
21122	Genioplasty; sliding osteotomies, 2 or more
21123	Genioplasty; sliding, augmentation with interpositional bone grafts
21244	Reconstruction of mandible, extraoral, with transosteal bone plate
21245	Reconstruction of mandible or maxilla, subperiosteal implant; partial
21246	Reconstruction of mandible or maxilla, subperiosteal implant; complete
21247	Reconstruction of mandibular condyle with autografts
21248	Reconstruction of mandible or maxilla, endosteal implant; partial
21249	Reconstruction of mandible or maxilla, endosteal implant; complete

Orthopedics / Extremity ProceduresCPTCovered

21685	Hyoid myotomy and suspension
21740	Reconstructive repair of pectus excavatum or carinatum; open
21742	Reconstructive repair of pectus excavatum; minimally invasive (Nuss), without thoracoscopy
21743	Reconstructive repair of pectus excavatum; minimally invasive, with thoracoscopy

Spine / Manipulation Under AnesthesiaCPTCovered

22505	Manipulation of spine requiring anesthesia, any region
22526	Percutaneous intradiscal electrothermal annuloplasty; single level (EIU)
22527	Percutaneous intradiscal electrothermal annuloplasty; additional levels (EIU)
22586	Arthrodesis, pre-sacral interbody technique, L5-S1 (EIU)

Selected Orthopedic Unlisted/Revision CodesCPTCovered

22899	Unlisted procedure, spine
23929	Unlisted procedure, shoulder
27299	Unlisted procedure, pelvis or hip joint
27702	Arthroplasty, ankle; with implant (total ankle)
27703	Arthroplasty, ankle; revision, total ankle
27704	Removal of ankle implant

Hand / Upper Extremity ProceduresCPTCovered

24300	Manipulation, elbow, under anesthesia
25259	Manipulation, wrist, under anesthesia
26340	Manipulation, finger joint, under anesthesia, each joint
26341	Manipulation, palmar fascial cord post enzyme injection, single cord

Hip / Pelvis ProceduresCPTCovered

27257	Treatment of spontaneous hip dislocation by abduction/splint/traction with manipulation requiring anesthesia
27275	Manipulation, hip joint, requiring general anesthesia
27278	Arthrodesis, sacroiliac joint, percutaneous with image guidance (MP or EIU depending on dates)

Foot / Ankle / Lower ExtremityCPTCovered

27702	Arthroplasty, ankle; with implant
27703	Arthroplasty, ankle; revision
27704	Removal of ankle implant
27860	Manipulation of ankle under general anesthesia
28890	Extracorporeal shock wave, high energy, requiring anesthesia; plantar fascia

Arthroscopy / Cartilage RepairCPTCovered

29862	Arthroscopy, hip, with debridement/shaving of articular cartilage
29866	Arthroscopy, knee; osteochondral autograft (mosaicplasty)
29867	Arthroscopy, knee; osteochondral allograft
29868	Arthroscopy, knee; meniscal transplantation

Additional Orthopedic/Arthroplasty CodesCPTCovered

29914	Arthroscopy, hip, with femoroplasty
29915	Arthroscopy, hip, with acetabuloplasty
29916	Arthroscopy, hip, with labral repair
29999	Unlisted procedure, arthroscopy

MiscellaneousCPTCovered

30468	Repair of nasal valve collapse with implant(s) (EIU)
30469	Repair of nasal valve collapse with radiofrequency remodeling (EIU)
31242	Nasal/sinus endoscopy with destruction by radiofrequency ablation, posterior nasal nerve
31243	Nasal/sinus endoscopy with cryoablation, posterior nasal nerve

Instructional Notemixed

KEY	This block consolidates multiple CPT groups from the source and preserves MP Criteria / EIU designations where provided; see document for effective date ranges and submission guidance.

What providers must do

Prior Authorization

Recommended Clinical Review / Prior Authorization

Submit procedure codes listed as MP Criteria for Recommended Clinical Review (predetermination/prior authorization) before providing the service to avoid denial on post‑service review. When a code entry is labeled "MP Criteria" the procedure/service is reviewed against Medical Policy Criteria; submit supporting clinical documentation and the applicable predetermination/prior authorization request per contract.

Submit MP Criteria codes for Recommended Clinical Review / Predetermination (prior authorization) to avoid post‑service review or claim denial.
Include clinical documentation that demonstrates how the request meets the Medical Policy (MP) clinical criteria.
Use searchable PDF or electronic submission channels as required by the plan.

Documentation Required

MP Criteria: Recommended Clinical Review

Policy context and scope

Background: This file is a utilization management code list intended to indicate which procedure codes in plastic/reconstructive surgery and related specialties are designated as MP Criteria (requiring medical policy review/submission for Recommended Clinical Review), EIU (not reimbursed), Non Covered (not covered), or Unlisted/Undefined. Its purpose is to guide submission and review workflows to avoid post‑service denials.

Key terms and definitions

MP Criteria definition

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

Action advisedHighlighted services in MP Criteria groups may also require prior authorization per contract

ScopeApplies to multiple CPT/HCPCS entries throughout the code list where 'MP Criteria' is indicated

Non Covered definition

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

Implication for claimsServices listed as Non Covered will not be reimbursed and are not eligible for pre-service determination

OpenPayer

Utilization Management Process — Procedure Code List (Plastic/Reconstructive Surgery codes)

Coverage criteria and designations

Procedure and billing codes

What providers must do

Policy context and scope

Key terms and definitions

Document revision history