Blue Cross Blue Shield Texas ASO code list Coverage

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.

MP Criteria group: Procedure/service reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (Predetermination) 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):

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

Applies to many CPT codes in the list (e.g., 15820-15839, 15847, 15876-15879, etc.).

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

Examples include codes 17340, 20560-20561, 22526-22527, 28890, 30468-30469, etc.

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

Examples include codes 21032, 21248-21249.

Code-based coverage groups

Coverage stance is code-specific and tied to review categories noted in the list.

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

Examples: 37215-37218, 37241-37244, many bariatric and transplant codes

EIU entries: Procedures labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; consult the EIU policy for details.

Examples: 36837, 43206, 43252, 43290, 43291, 46707

Coverage categories in list

Coverage stance by code group as listed in this segment

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

Applies to many codes listed (see code_groups).

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

Claims likely denied as not reimbursed.

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

Explicit non-covered codes (e.g., artificial insemination codes).

Coverage groups and guidance

Coverage stance is determined per code group as listed below:

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

Examples include 62263, 62264, 64628, 64629, 82523, 83695, 83698.

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.

Examples include many surgical and device implantation codes listed across chunks 91-107.

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

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:

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

examples: 90889 (Non Covered), 91065 (EIU)

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

examples: 92622, 93228, 96547

Unlisted procedure codes may require contract/clinical review and prior authorization per contract; coverage depends on review.

examples: 37501, 38589

Coverage categories and action notes

Coverage and review instructions as listed

MP Criteria requirement: Codes labeled 'MP Criteria' should be submitted for Recommended Clinical Review to avoid post-service review

Applies to codes such as 96001, 96002, 96004, 96547, 96548, 0071T, 0072T, 0105U

EIU / Not reimbursed: Codes labeled EIU are not reimbursed by the plan and are not subject to pre-service review; check the EIU/CPCP policy for details

Examples: 97610, 0052U, 0054T, 0055T

Non Covered: Codes labeled 'Non Covered' are not covered by the plan and are not subject to pre-service review

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:

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

Billing these codes will generally result in nonpayment.

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

Medical policy criteria apply; coverage depends on meeting those criteria.

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

Coverage determined after review; prior auth may be needed.

Coverage classifications in code list

Coverage stance by code group as listed in this excerpt:

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

Examples include leadless pacemaker insertion/removal/replacement and programming codes (e.g., 0795T-0804T, 0823T-0826T, 0801T-0803T, 0861T-0863T, 0870T-0873T)

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 Clinical Payment and Coding Policy (CPCP).

Examples: 0807T, 0808T, 0813T, 0816T, 0818T, 0858T, 0864T, 0868T (date-specific)

Non Covered: Codes labeled 'Non Covered' are not covered by the Plan and are not subject to pre-service review.

Examples: 0811T, 0812T

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

MP Criteria: Procedure/service reviewed against Medical Policy CriteriaCPTCovered

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).

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EIU: Procedure/service not reimbursed by the PlanCPTNot Covered

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).

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MP Criteria: Procedure/service reviewed against Medical Policy Criteria - Cardiac / Leadless Pacemaker & RelatedCPTCovered

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.

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Actions for Providers — Predetermination, Prior Authorization, Documentation

Prior Authorization

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.

Documentation Required

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.

Key Definitions and Terms

Non Covered definition

DefinitionProcedures/services not covered by the Plan. Not subject to pre-service review.

ActionDo not submit for pre-service Recommended Clinical Review; claims for Non Covered services will be denied as not covered.

ExamplesSee code list entries labeled 'Non Covered' (e.g., 86910, 86911, necropsy codes 88000 series).

Experimental, Investigational, Unproven (EIU) definition

DefinitionExperimental, Investigational, Unproven (EIU): Procedure/service considered experimental, investigational, and/or unproven per Medical Policy Coverage statement; procedure/service not reimbursed by the Plan and not subject to pre-service review.

ActionDo not submit for pre-service review; billing EIU-coded procedures will generally result in denial for non-reimbursement; consult the EIU section of the Clinical Payment and Coding Policy (CPCP) for details.

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.

OpenPayer

2025 Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List (ASO)

Coverage Criteria and Code Group Classifications

Code Tables and Grouped Code Listings

Actions for Providers — Predetermination, Prior Authorization, Documentation

Key Definitions and Terms

Policy Background and Scope