2025 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List (ASO)
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Administrative code list describing procedure code groupings (Recommended Clinical Review, Post-Service Review, Non-Covered, Experimental/Unproven, Unlisted) and effective dates for Administrative Services Only (ASO) contracts, used to guide utilization management and prior authorization for Blue Cross Blue Shield - Texas.
No material clinical or coverage changes in this revision.
Coverage Criteria and Code Group Classifications
MP Criteria (Predetermination required)
Codes are grouped and described; submit for Recommended Clinical Review when listed under MP Criteria to avoid post-service review.
Highlighted procedures may require Prior Authorization per contract
Classification and review requirements
Coverage classification and review requirement as listed (examples):
Applies to many CPT codes in the list (e.g., 15820-15839, 15847, 15876-15879, etc.).
Examples include codes 17340, 20560-20561, 22526-22527, 28890, 30468-30469, etc.
Examples include codes 21032, 21248-21249.
Code-based coverage groups
Coverage stance is code-specific and tied to review categories noted in the list.
Examples: 37215-37218, 37241-37244, many bariatric and transplant codes
Examples: 36837, 43206, 43252, 43290, 43291, 46707
Coverage categories in list
Coverage stance by code group as listed in this segment
Applies to many codes listed (see code_groups).
Claims likely denied as not reimbursed.
Explicit non-covered codes (e.g., artificial insemination codes).
Coverage groups and guidance
Coverage stance is determined per code group as listed below:
Examples include 62263, 62264, 64628, 64629, 82523, 83695, 83698.
Examples include many surgical and device implantation codes listed across chunks 91-107.
Examples include 15999, 17999, 19499, 20999, 21299, 21499, 21899, 22899, 22999, 23929, 24999, 25999, 26989, 27299.
Coverage by Code Group
Coverage stance is determined by code group labels:
examples: 90889 (Non Covered), 91065 (EIU)
examples: 92622, 93228, 96547
examples: 37501, 38589
Coverage categories and action notes
Coverage and review instructions as listed
Applies to codes such as 96001, 96002, 96004, 96547, 96548, 0071T, 0072T, 0105U
Examples: 97610, 0052U, 0054T, 0055T
Examples: 97810-97814, 99026-99082, 99450, 99455-99456
Coverage groupings: EIU, MP Criteria, Unlisted
Codes in this list are assigned to one of three stances with associated requirements:
Billing these codes will generally result in nonpayment.
Medical policy criteria apply; coverage depends on meeting those criteria.
Coverage determined after review; prior auth may be needed.
Coverage classifications in code list
Coverage stance by code group as listed in this excerpt:
Examples include leadless pacemaker insertion/removal/replacement and programming codes (e.g., 0795T-0804T, 0823T-0826T, 0801T-0803T, 0861T-0863T, 0870T-0873T)
Examples: 0807T, 0808T, 0813T, 0816T, 0818T, 0858T, 0864T, 0868T (date-specific)
Examples: 0811T, 0812T
Examples: 93799, 93998, 94799, 95999, 96379, 96549, 97039, 97139, 97799
Procedures and services marked Non Covered in this code list are not a benefit under the Plan. These items are not subject to pre‑service review and billing for them will not be reimbursed. The code list is provided for administrative guidance covering the ASO code list effective 1/1/2025 through 1/1/2026.
Examples of codes explicitly designated Non Covered in the list include 21032 (Excision of maxillary torus palatinus). Entries flagged as Non Covered indicate the procedure/service is not covered by the Plan and not subject to pre‑service review.
Codes labeled EIU (Experimental, Investigational, or Unproven) in this document are described as ‘Procedure/service not reimbursed by the Plan’. EIU entries are not subject to pre‑service review and reference the Plan’s EIU/CPCP policy for details; examples in this segment include procedures such as 30468, 30469, 31242, 31243, 33276–33278, 36473–36474, 36836–36837.
Summary: codes designated EIU are excluded from reimbursement under the Plan — they are not reimbursed and not subject to pre‑service review. Providers should consult the EIU policy (Clinical Payment and Coding Policy) when these codes are billed.
Explicit Non Covered examples called out in the list include reproductive services such as 58321, 58322, 58323 (artificial insemination and related procedures) and 58750 (tubotubal anastomosis). These are labeled Non Covered and are not subject to pre‑service review.
The list contains multiple entries marked EIU across specialties — urology, ENT, vascular and others — indicating a recurring classification where specific procedures are classified as not reimbursed by the Plan. Examples include periurethral devices, nasal valve implants, and select endovenous procedures.
Specific EIU codes cited in the list include interventional pain and diagnostic lab codes such as 62263, 62264 (adhesiolysis procedures) and laboratory assays like 82523, 83695, 83698; each is explicitly labeled EIU: not reimbursed by the Plan.
The policy language for EIU entries reiterates that procedures/services designated EIU are not reimbursed by the Plan and are not subject to pre‑service review; providers are directed to the EIU policy in the Clinical Payment and Coding Policy (CPCP) for further details.
Many necropsy/autopsy procedures in the 88000 series are specifically listed as Non Covered. These autopsy/necropsy entries are not subject to pre‑service review and will not be reimbursed by the Plan.
Summary: Procedures classified either Non Covered or EIU are excluded from reimbursement by the Plan and will not be paid if billed. The code list is an administrative reference that flags those codes accordingly.
Note: the EIU designation appears alongside a recommendation to consult the Plan’s EIU/CPCP policy. The list clarifies that EIU entries are not reimbursed and are not subject to pre‑service review; check the CPCP for policy rationale and any date‑specific exceptions.
Multiple EIU descriptions across the document consistently state: EIU — Procedure/service not reimbursed by the Plan. Not subject to pre‑service review. Check EIU policy (CPCP). These entries span diagnostic, laboratory, and procedural codes and may include effective/ending dates where applicable.
Continued EIU exclusions: the code list repeatedly marks many procedures and diagnostic tests as EIU (not reimbursed). The listing format advises providers that billing these codes will generally result in nonpayment and points to the EIU/CPCP guidance for specifics.
Reminder: EIU entries are an exclusion category within this administrative code list — they are not reimbursed and not subject to pre‑service review. Providers should consult the EIU policy for interpretation and any contract‑specific rules.
The document labels numerous codes as EIU (Experimental, Investigational, or Unproven) and reiterates that such procedures/services are not reimbursed by the Plan. This classification appears across modalities (imaging, lab, procedure codes) and serves as an explicit exclusion from payment.
Procedures listed as EIU include newer surgical and transplant‑related codes (for example, donor/recipient uterine transplant codes such as 0667T–0670T) and are explicitly flagged as not reimbursed by the Plan in this code list.
Where EIU entries appear, the list references the Clinical Payment and Coding Policy (CPCP) and indicates these services are not reimbursed. The administrative code list therefore functions as the Plan’s operational flagging mechanism for excluded (EIU) codes.
Short summary: the code list classifies codes into MP Criteria (submit for Recommended Clinical Review), EIU (not reimbursed) and Unlisted (may require contract/clinical review). EIU entries are an explicit exclusion from reimbursement.
Code Tables and Grouped Code Listings
| 11960 | Insertion of tissue expander(s) for other than breast, including subsequent expansion. |
| 11970 | Replacement of tissue expander with permanent implant. |
| 11980 | Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin). |
| 15011 | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less. |
| 15012 | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof (List separately). |
| 15013 | Preparation of skin cell suspension autograft, requiring enzymatic processing...; first 25 sq cm or less of harvested skin. |
| 15014 | Preparation of skin cell suspension autograft; each additional 25 sq cm... (List separately). |
| 15015 | Application of skin cell suspension autograft to wound and donor sites...; first 480 sq cm or less. |
| 15016 | Application of skin cell suspension autograft... each additional 480 sq cm or part thereof (List separately). |
| 15017 | Application of skin cell suspension autograft... first 480 sq cm or less (special sites). |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified. |
| 17340 | Cryotherapy for acne (CO2 slush, liquid N2) - EIU not reimbursed. |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscles (EIU - not reimbursed). |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles (EIU - not reimbursed). |
| 20985 | Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (EIU - not reimbursed). |
| 20999 | Unlisted procedure, musculoskeletal system (Unlisted group referenced). |
| 20985 | (duplicate listing for reference) |
| 31660 | Bronchoscopy with bronchial thermoplasty (EIU effective dates vary). |
| 31661 | Bronchoscopy with bronchial thermoplasty, 2+ lobes (EIU). |
| 36836 | Percutaneous arteriovenous fistula creation (EIU - not reimbursed in segment). |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker; complete system (RA and RV components). |
| 0796T | Transcatheter insertion of dual-chamber leadless pacemaker; right atrial component when existing RV single leadless pacemaker exists. |
| 0797T | Transcatheter insertion of dual-chamber leadless pacemaker; right ventricular component when part of dual-chamber system. |
| 0798T | Transcatheter removal of permanent dual-chamber leadless pacemaker; complete system. |
| 0799T | Transcatheter removal of permanent dual-chamber leadless pacemaker; right atrial component. |
| 0800T | Transcatheter removal of permanent dual-chamber leadless pacemaker; right ventricular component. |
| 0801T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker; dual-chamber system. |
| 0802T | Transcatheter removal and replacement; right atrial pacemaker component. |
| 0803T | Transcatheter removal and replacement; right ventricular pacemaker component. |
| 0804T | Programming device evaluation (in person) with iterative adjustment for leadless pacemaker system in dual cardiac chambers. |
Actions for Providers — Predetermination, Prior Authorization, Documentation
Submission and prior authorization guidance
Our medical policy impacts coverage decisions for listed CPT and HCPCS codes. Providers should submit Medical Policy Criteria (MP Criteria) codes and other procedures reviewed against Medical Policy for Recommended Clinical Review (predetermination) to avoid post-service review. Some MP Criteria codes or highlighted services may also require Prior Authorization per contract. Predetermination helps avoid denials or retrospective review.
- Submit MP Criteria codes for Recommended Clinical Review (predetermination) to avoid post-service review.
- Highlighted procedures may require Prior Authorization per contract — check member plan.
- Predetermination reduces risk of post-service denials.
MP Criteria — Recommended Clinical Review required
Medical Policy Criteria (MP Criteria) codes require Recommended Clinical Review (predetermination). Submit documentation supporting medical necessity at time of request to prevent post-service review.
- MP Criteria codes = submit for Recommended Clinical Review (Predetermination).
- Provide clinical documentation, operative reports, imaging, and prior conservative therapy details as applicable.
EIU — Not reimbursed / no pre-service review
Some codes in this list are designated EIU (Experimental/Investigational/Unproven) and are not reimbursed. EIU procedures are not subject to pre-service review — submitting a predetermination will not change coverage.
- EIU = Not reimbursed by the Plan; not subject to pre-service review.
- Check the Clinical Payment and Coding Policy (CPCP) for details on EIU codes.
Non Covered — no pre-service review
Non-covered procedures are not benefits under the Plan and are not subject to pre-service review. Do not submit predetermination requests for services listed as Non Covered; obtain patient acknowledgment when appropriate.
- Non Covered = Procedure/service not covered by the Plan; not subject to pre-service review.
- Examples in this section include select reproductive and fertility services and others listed in the code list.
Recommended Clinical Review required (Selected codes)
Selected procedure codes are reviewed against Medical Policy Criteria and require Recommended Clinical Review to confirm medical necessity. Submissions should include all relevant supporting documentation to avoid post-service review.
Excluded / Not reimbursed (EIU) — provider reminder
Codes designated EIU are excluded/not reimbursed. Providers should not expect payment for these services; billing may be denied. Confirm EIU status before scheduling.
Recommended Clinical Review requirement overview
Provide comprehensive documentation when submitting requests for Recommended Clinical Review or prior authorization. Include history, prior treatments, imaging, pathology, and rationale tying the requested service to Medical Policy criteria.
- Documentation should be sufficient to demonstrate medical necessity per the referenced Medical Policy.
- Incomplete submissions may result in delays or post-service denial.
Recommended Clinical Review for MP Criteria codes
MP Criteria codes listed throughout require Recommended Clinical Review (predetermination). Submitting these ahead of service helps determine coverage and reduces retrospective denials.
- Examples: 43845-43848, 43886-43888; many bariatric and related procedures are MP Criteria.
- When in doubt, submit a predetermination for MP Criteria-coded services.
Submit MP Criteria/unlisted codes for Recommended Clinical Review
If a service is represented by an unlisted procedure code or an MP Criteria/unlisted combination, submit for Recommended Clinical Review with detailed clinical documentation; prior authorization may also be required per contract.
Prior authorization may be required for unlisted procedure codes
Unlisted procedure codes may require prior authorization per contract and often need detailed documentation to support coverage. Submit clinical rationale and comparators (if applicable).
Prior authorization / Recommended Clinical Review
Predetermination (Recommended Clinical Review) is encouraged for MP Criteria and unlisted codes to avoid post-service review and claim denials. When required by contract, obtain Prior Authorization before performing the service.
- Transcatheter and device procedures (eg, 0795T-0799T series, 0823T) are MP Criteria and often require predetermination.
- Check member-specific benefits for Prior Authorization requirements.
Key Definitions and Terms
Policy Background and Scope
Background: this document is an administrative, code‑level listing used to indicate whether specific procedures are Non Covered, designated EIU (Experimental/Investigational/Unproven), or should be submitted as MP Criteria for Recommended Clinical Review. The list guides utilization management and prior authorization actions for ASO contracts effective 1/1/2025.
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