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CurrentBlue Cross Blue Shield - TexasPolicy N/A

Recommended Clinical Review, Post‑Service Review and Non‑Covered Procedure Code List — Plastic/Reconstructive Surgery (Fully Insured)

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A searchable list of procedure codes related to plastic and reconstructive surgery that are candidates for Recommended Clinical Review, subject to medical necessity review, or designated non‑covered; applies to providers and claim reviewers for Blue Cross Blue Shield - Texas fully insured members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review, Post‑Service Review and Non‑Covered Procedure Code List — Plastic/Reconstructive Surgery (Fully Insured)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2025

Last ReviewOct 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyprocedure codes listed (partial)

multipleMP Criteria (require clinical review)

severalEIU / Not reimbursed codes

MP Criteria, Unlisted, EIU

group classifications

through 12/31/2999common effective/ending dates

Coverage Criteria and Review Designations

inv-01: Recommended Clinical Review / MP Criteria

Codes are categorized and reviewed against Medical Policy Criteria; submit for Recommended Clinical Review when labeled MP Criteria.

Submit for Recommended Clinical Review: Procedure/service labeled 'MP Criteria' must be submitted for Recommended Clinical Review to avoid post-service review; prior authorization may be required per contract for some codes.

Administrative requirement from code table

inv-02: Coverage grouping and required review actions

Coverage and review stance is indicated per code grouping

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

examples: 17106, 17107, 17108, 17360, 17380, 19105, 19318, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19370, 19371

Non Covered items: Codes labeled 'Non Covered' are not covered by the Plan (e.g., 20560, 20561, 21032) and are not subject to pre-service review.

Claims for these codes are expected to be denied as not covered.

EIU items: Codes labeled 'EIU' are excluded from reimbursement (not reimbursed) and not subject to pre-service review; check EIU/CPCP guidance.

examples: 20985, 27278, 22836-22838

Unlisted items: Unlisted procedure codes may require contract/clinical review and prior authorization per contract; submit documentation to support medical necessity.

numerous unlisted codes across surgical specialties in the excerpt.

inv-03: Utilization management label groups

Coverage and review stance is indicated per-code with three primary labels in this excerpt:

MP Criteria: Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and the document directs submitting for Recommended Clinical Review to avoid post-service review.

Examples: 27702, 29862, 31647, 33211, 33361

EIU (Not reimbursed): Codes labeled 'EIU' are listed as procedure/service not reimbursed by the Plan and are not subject to pre-service review; providers should check the EIU policy in the Clinical Payment and Coding Policy.

Examples: 27278, 30468, 30469, 31242, 33276

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: 26989, 27299, 29999, 30999

inv-04: Codes requiring Recommended Clinical Review

Coverage determinations are tied to specific codes and their designated review/status

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

Applies to many listed CPT codes (examples: 33366, 33367, 33477, 33927, 36465, 37215, 38204)

inv-05: Unlisted / Not reimbursed codes

Special handling codes

Unlisted codes may require prior authorization: Codes labeled 'Unlisted' may be subject to contract/clinical review and prior authorization per contract agreement (examples: 33999, 36299, 37501, 38129).

Provider should submit additional documentation as requested.

EIU - Not reimbursed: Codes labeled EIU (eg, 0264T, 0265T, 0566T) are noted as not reimbursed by the Plan.

Billing these codes may result in denial.

inv-06: Post-service review

Some codes are selected for post-service review

Post-service review: Certain codes (e.g., 36482, 36483) are indicated for submission and may be subject to post-service review.

Recommended Clinical Review may be specified to avoid post-service review for related codes.

inv-07: MP Criteria — Recommended Clinical Review

Covered when submitted for Recommended Clinical Review where MP Criteria is indicated

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

applies to codes annotated as MP Criteria

inv-08: Coverage approach by code label

Coverage and review approach is determined by code group labels in the document.

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

Applies to codes marked MP Criteria such as 47370, 47382, 47383, 51715, 52327

EIU (Excluded): Procedure/service not reimbursed by the Plan (EIU); not subject to pre-service review per EIU designation.

Applies to codes labeled EIU such as 43206, 43252, 52284, 53451-53454

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

Applies to numerous unlisted CPTs across specialties.

Non Covered: Some procedures are explicitly Non Covered (not a benefit) and are not subject to pre-service review.

inv-09: Coverage group logic

Coverage/status is specified per code as follows

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

Examples: selected lab and reproductive storage codes (e.g., 83698, 83701, 89258)

Unlisted codes are not specifically defined or classified and may be subject to contract/clinical review; prior authorization may be required per contract agreement.

Examples: 84999, 85999, 88299, 88399

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

Examples: 86353, 90867-90869

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

inv-10: MP Criteria — require clinical review

Covered when reviewed and meet Medical Policy Criteria

MP Criteria codes: Services coded with 'MP Criteria' must be reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review.

Specific clinical criteria are in the referenced Medical Policy; not included in this excerpt.

inv-11: Per-code designation: MP Criteria vs EIU/not reimbursed

Coverage stance is conveyed per-code by the Plan's designations:

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.

Examples: selected T-codes and device procedure codes (e.g., 0270T-0273T, 0308T, 0440T-0442T)

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

Examples: 0274T, 0335T, many central sleep apnea codes (0424T-0429T)

inv-12: Recommended Clinical Review (MP Criteria)

Covered when submitted for Recommended Clinical Review and meet Medical Policy Criteria

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

Providers must submit required clinical documentation to Recommended Clinical Review.

inv-13: Experimental / Investigational / Unproven (EIU)

Not covered / not reimbursed

EIU - Not reimbursed: Procedure/service is designated EIU (experimental/investigational/unproven) and is not reimbursed by the Plan.

These services are not subject to pre-service review; check EIU policy references.

inv-14: Coverage designations by code group

Coverage stance is assigned per code as follows

MP Criteria codes: Codes labeled 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' require submission for Recommended Clinical Review to avoid post-service review.

Examples: 0747T, 0765T, 0784T, 0785T, 0795T-0806T

EIU (Not reimbursed): Codes labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed; check the EIU policy within the Clinical Payment and Coding Policy (CPCP).

Examples: 0748T, 0766T-0769T, 0770T-0774T, 0599T, 0603T

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

Examples: 0811T, 0812T

This code list is an administrative mapping of procedure codes to the Plan's utilization management classifications. Codes labeled MP Criteria are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review (predetermination) to avoid post‑service review. Codes labeled Non Covered or EIU (Experimental, Investigational and Unproven) are not benefits under the Plan and are excluded from coverage or reimbursement as indicated.

Specific examples in the list illustrate the Plan’s exclusions: several codes are explicitly designated Non Covered and therefore not reimbursable (for example, the needle insertion codes 20560, 20561), and other codes are designated EIU (for example, 20985, 22526, 22527 in the excerpt) and are explicitly excluded from reimbursement. Providers should treat codes in these groups as not payable by the Plan.

Procedures labeled EIU are identified as "Procedure/service not reimbursed by the Plan" and, per the document, are not subject to pre‑service review. The listing directs providers to consult the Plan’s EIU / Clinical Payment and Coding Policy for details; billing EIU‑designated codes will result in denial for reimbursement.

The code table includes multiple entries where the code group is shown as EIU: Procedure/service not reimbursed by the Plan (for example 33276 and codes in the 30468–31243 range). These items are treated as excluded from reimbursement and are not eligible for pre‑service predetermination under the EIU designation.

The EIU designation is described in the file as "Procedure/service not reimbursed by the Plan" and the listing references the Plan’s EIU policy (Clinical Payment and Coding Policy) for further guidance. Providers should note that items marked EIU will not be reimbursed and are not generally subject to the Recommended Clinical Review process.

The document repeatedly states that codes tagged EIU are treated as 'Procedure/service not reimbursed by the Plan.' Where present, the EIU label serves as an explicit exclusion from reimbursement and refers providers to the EIU/CPCP for policy rationale.

Codes marked EIU in the listing are described as not reimbursed by the Plan and therefore excluded from coverage. The file makes clear that EIU entries represent denial/nonpayment risk if billed to the Plan.

Certain fertility procedures are explicitly labeled Non Covered: Procedure/service not covered by the Plan. The list includes 58321, 58322, 58323 (artificial insemination and sperm washing) as examples that are not covered and not subject to pre‑service review.

Any code explicitly labeled Non Covered in the table (examples include 58321–58323, 58750, 65760) is not a Plan benefit and will be denied if submitted. These codes are not eligible for pre‑service Recommended Clinical Review because they are outside Plan coverage.

The listing identifies several laboratory/lipoprotein tests as Non Covered, for example 82523, 83695, 83698, 83701, 83704, 83722. These entries are designated as not covered by the Plan and are not subject to pre‑service review.

Additional laboratory and reproductive services are explicitly excluded in the file. Codes such as 83698, 83701 and cryopreservation/storage codes (for example 89342–89346) are flagged Non Covered and therefore excluded from reimbursement.

A number of diagnostic and therapeutic procedure codes are labeled Non Covered in the excerpt (for example 92065, 92548, 94452, 94453, 97810–97814). When a code is listed as Non Covered, it is not payable by the Plan and is not subject to pre‑service review.

Code Listings and Grouped Code Tables

MP Criteria / Recommended Clinical Review (examples)CPT

00797

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity.

MP Criteria / Recommended Clinical Review (injectable fillers)CPT

11950	Subcutaneous injection of filling material (eg, collagen); 1.
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc.
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0cc.
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 CC.

MP Criteria / Skin substitute and tissue expander codesCPT

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).
15271	Application of skin substitute to trunk,; arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area graft.
15272	Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area.
15273	Application of skin substitute to trunk, arms, legs, total wound surface area greater than or equalto 100 sq cm; first 100 sq cm wound surface area.
15274	Application of skin substitute to trunk; arms, legs, total wound surface area greater than or equalto 100 sq cm; each additional 100 sq cm wound surface area.

MP Criteria / flap, grafting, and skin substitute (examples)CPT

15275	Application of skin substitute graft to face, scalp, eyelids, multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.
15276	Application of skin substitute to face, scalp, eyelids, multiple digits; each additional 25 sq cm wound surface area.
15277	Application of skin substitute to face, scalp, eyelids, multiple digits, total wound surface area >= 100 sq cm; first 100 sq cm.
15278	Application of skin substitute to face, scalp, eyelids... each additional 100 sq cm wound surface area.
15758	Free fascial flap with microvascular anastomosis.
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia).
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Grafting of autologous fat harvested by liposuction technique; each additional 50 cc injectate.

MP Criteria / resurfacing and chemical peel codesCPT

15780	Dermabrasion; total face (eg, for acne scarring; fine wrinkling; rhytids, general keratosis).
15781	Dermabrasion; segmental; face.
15782	Dermabrasion; regional, other than face.
15783	Dermabrasion; superficial, any site (eg, tattoo removal).
15786	Abrasion; single lesion (eg, keratosis, scar).
15787	Abrasion; each additional 4 lesions or less.
15788	Chemical peel, facial; epidermal.
15789	Chemical peel; facial; dermal.
15792	Chemical peel, nonfacial; epidermal.
15793	Chemical peel, nonfacial; dermal.

MP Criteria / excision, blepharoplasty, rhytidectomyCPT

15820	Blepharoplasty, lower eyelid.
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad.
15822	Blepharoplasty, upper eyelid.
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid.
15825	flap, P-flap (partial descriptor in source).
15828	Rhytidectomy; cheek, chin, and neck.
15829	Rhytidectomy; SMAS flap.
15830	Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy.
15832	Excision, excessive skin and subcutaneous tissue; thigh.
15833	Excision, excessive skin and subcutaneous tissue; leg.

1–10 of 16

1/2

MP Criteria / lipectomy and suction-assisted lipectomyCPT

15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication).
15876	Suction assisted lipectomy; head and neck.
15877	Suction assisted lipectomy; trunk.
15878	Suction assisted lipectomy; upper extremity.
15879	Suction assisted lipectomy; lower extremity.

MP Criteria / assorted codes including unlisted, destruction, breast proceduresCPT

15999	Unlisted procedure, excision pressure ulcer.
17106	Destruction of cutaneous vascular proliferative lesions; less than 10 sq cm.
17107	Destruction of cutaneous vascular proliferative lesions; 10.0 to 50.0 sq cm.
17108	Destruction of cutaneous vascular proliferative lesions; over 50.0 sq cm.
17360	Chemical exfoliation for acne (eg, acne paste, acid).
17380	Electrolysis epilation, each 30 minutes.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
19105	Ablation, cryosurgical; of fibroadenoma, including ultrasound guidance, each fibroadenoma.
19300	Mastectomy for gynecomastia.
19318	Breast reduction.

1–10 of 11

1/2

Mixed listing (Unlisted/MP Criteria/Procedures)CPT

15999	Unlisted procedure, excision pressure ulcer.
17106	Destruction of cutaneous vascular proliferative lesions; less than 10 sq cm.
17107	Destruction of cutaneous vascular proliferative lesions; 10.0 to 50.0 sq cm.
17108	Destruction of cutaneous vascular proliferative lesions; over 50.0 sq cm.
17360	Chemical exfoliation for acne (eg, acne paste, acid).
17380	Electrolysis epilation, each 30 minutes.

Breast/plastic surgery related codes (MP Criteria/Unlisted)CPT

17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
19105	Ablation, cryosurgical; of fibroadenoma, including ultrasound guidance, each fibroadenoma.
19300	Mastectomy for gynecomastia.
19318	Breast reduction.
19325	Breast augmentation with implant.
19330	Removal of ruptured breast implant; including implant contents (eg, saline, silicone gel).
19340	Insertion of breast implant on same day of mastectomy (ie, immediate).
19342	Insertion or replacement of breast implant on separate from mastectomy day.
19350	Nipple/areola reconstruction.
19355	Correction of inverted nipples.

1–10 of 14

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Non Covered CodesCPTNot Covered

20560	Needle insertion(s) without injection(s); 1 or 2 muscle(s).
20561	Needle insertion(s) without injection(s); 3 or more muscles.

Maxillofacial and related codes (MP Criteria/Unlisted/EIU)CPT

20982	Ablation therapy for reduction or eradication of 1 or more bone tumors; radiofrequency.
20983	Ablation therapy for reduction or eradication of 1 or more bone tumors; cryoablation.
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures image-less.
20999	Unlisted procedure, musculoskeletal system, general.
21032	Excision of maxillary torus palatinus.
21083	Impression and custom preparation; palatal lift prosthesis.
21089	Unlisted maxillofacial prosthetic procedure.
21120	Genioplasty; augmentation (autograft; allograft, prosthetic material).
21121	Genioplasty; sliding osteotomy, single piece.
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies.

1–10 of 17

1/2

Spine, musculoskeletal, and other unlisted/EIU codesCPT

21685	Hyoid myotomy and suspension.
21899	Unlisted procedure, neck or thorax.
22526	Percutaneous intradiscal electrothermal annuloplasty; single level.
22527	Percutaneous intradiscal electrothermal annuloplasty; additional levels.
22586	Arthrodesis pre-sacral interbody technique including disc space preparation.
22836	Anterior thoracic vertebral body tethering; up to 7 vertebral segments.
22837	Anterior thoracic vertebral body tethering; 8 or more vertebral segments.
22838	Revision/replacement/removal of thoracic vertebral body tethering.
22867	Insertion of interlaminar/interspinous process stabilization/distraction device without fusion with open decompression; single level.
22868	Insertion of interlaminar/interspinous process stabilization/distraction device without fusion; second level.

1–10 of 22

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Sample codes — excerpt startCPT

26989	Unlisted procedure, hands or fingers.
27278	Arthrodesis sacroiliac joint percutaneous with image guidance including placement of intra-articular implant(s) without placement of transfixation device.
27299	Unlisted procedure, pelvis or hip joint.
27599	Unlisted procedure, femur or knee.
27702	Arthroplasty, ankle; with implant (total ankle).

Arthroscopy/orthopedics-related codesCPT

27703	Arthroplasty, ankle; revision, total ankle.
27899	Unlisted procedure, leg or ankle.
28899	Unlisted procedure, foot or toes.
29799	Unlisted procedure, casting or strapping.
29862	Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum.
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]).

Hip/knee arthroscopy and unlisted arthroscopyCPT

29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty).
29868	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral.
29914	Arthroscopy, surgical; with femoroplasty (ie, treatment of cam lesion) hip.
29915	Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.
29999	Unlisted procedure, arthroscopy.

ENT and nasal proceduresCPT

30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s).
30469	Repair of nasal valve collapse with low energy temperature-controlled (ie radiofrequency) subcutaneous/submucosal remodeling.
30999	Unlisted procedure, nose.
31242	Nasal/sinus endoscopy surgical; with destruction by radiofrequency ablation posterior nasal nerve.
31243	Nasal/sinus endoscopy surgical; with destruction by cryoablation posterior nasal nerve.

Bronchoscopy and pulmonary codesCPT

31299	Unlisted procedure, accessory sinuses.
31599	Unlisted procedure, larynx.
31647	Bronchoscopy; with balloon occlusion, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe.
31648	Bronchoscopy; with removal of bronchial valve(s), initial lobe.
31649	Bronchoscopy; with removal of bronchial valve(s), each additional lobe.
31651	Bronchoscopy; with balloon occlusion, assessment, insertion of bronchial valve(s), each additional lobe.

Provider Requirements and Billing Guidance

Prior Authorization

Contract-dependent prior authorization for Unlisted/Unusual codes

Certain unlisted procedure codes (for example 15999, 17999) and other services flagged as 'Unlisted' may require prior authorization per contract; providers must verify contract-specific prior authorization requirements and submit prior authorization when required.

Examples of unlisted codes calling out prior authorization: 15999 (Unlisted procedure, excision pressure ulcer) [[chunk 18]]
Many unlisted spine/pelvic/orthopedic codes note 'Prior Authorization may be required per contract agreement' (e.g., 22899, 22999, 27299) [[chunk 35]]
Provider action: check member contract for PA requirements before performing or billing Unlisted codes [[chunk 36]]

Prior Authorization

Submit MP Criteria codes for Recommended Clinical Review (predetermination)

Submit cases coded as 'MP Criteria' for Recommended Clinical Review (predetermination) prior to service when possible; failure to do so may trigger post-service review.

Document Purpose and Scope

This document is an administrative code‑level reference for utilization management: it assigns each CPT/HCPCS code a Plan designation (MP Criteria, Unlisted, Non Covered, or EIU) that determines whether the service should be submitted for Recommended Clinical Review, may require prior authorization per contract, or is excluded from coverage. It is not itself a clinical guideline but translates policy‑level coverage stances into per‑code actions.

Key Definitions and Term Glossary

inv-230: MP Criteria / Recommended Clinical Review

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

ActionSubmit cases coded as MP Criteria for Recommended Clinical Review prior to service when feasible; this reduces risk of post-service review and denial.

Prior AuthorizationSome MP Criteria items may also require Prior Authorization per contract — verify contract requirements.

inv-231: Unlisted or Undefined

DefinitionUnlisted or Undefined: Procedures/services not specifically defined or classified; may be subject to contract or clinical review and may require Prior Authorization per contract agreement.

Provider action

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review, Post‑Service Review and Non‑Covered Procedure Code List — Plastic/Reconstructive Surgery (Fully Insured)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2025

Last ReviewOct 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Examples appear elsewhere in the list (e.g., 20560, 20561, certain lab tests)

Examples: selected procedure and diagnostic codes designated EIU in the document

Codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria and the document directs 'Submit for Recommended Clinical Review to avoid post-service review' (examples in the code lists) [[chunk 18]]

Multiple procedures (e.g., TAVR-related codes 33366–33369) are explicitly noted as MP Criteria with instruction to submit for Recommended Clinical Review [[chunk 54]]

Selected Category III/T codes and other MP Criteria entries reiterate that Recommended Clinical Review is required to avoid post-service review [[chunk 216]]

Documentation Required

Include clinical justification when submitting Unlisted procedure codes

When billing Unlisted procedure codes, include supporting clinical documentation to justify medical necessity; unlisted codes may be subject to contract/clinical review and prior authorization.

Unlisted cardiac and vascular codes (e.g., 33999, 36299) are flagged as 'Unlisted' and note that Prior Authorization may be required per contract agreement [[chunk 56]]
Many unlisted surgical codes across specialties indicate prior authorization may be required and to submit clinical documentation as requested [[chunk 35]]
Ophthalmology unlisted codes (e.g., 66999, 67299) explicitly note potential contract/clinical review and PA requirements when billed [[chunk 128]]

Denial Risk

EIU-designated codes are not reimbursed — risk of denial

Do not expect pre-service review or reimbursement for codes designated EIU; billing these codes may result in denial because they are 'Procedure/service not reimbursed by the Plan.'

Examples of EIU/not reimbursed codes and language: 'EIU: Procedure/service not reimbursed by the Plan. Not subject to pre-service review' (e.g., 27278, 0599T) [[chunk 36]]
Noncontact fluorescence wound imaging codes 0598T/0599T and multiple other codes are labeled EIU and stated as not reimbursed [[chunk 234]]
The policy repeatedly states EIU-designated services are not subject to pre-service review and are not reimbursed [[chunk 203]]

Denial Risk

Risk: post-service review/denial if Recommended Clinical Review not submitted

Services submitted without meeting Recommended Clinical Review or without the required clinical documentation may be subject to post-service review and denial.

The file instructs that MP Criteria items should be submitted for Recommended Clinical Review to avoid post-service review; omission may trigger post-service review or denial [[chunk 1]]
Denial risk statement: 'Services submitted without meeting the recommended clinical review / medical policy criteria... may be subject to post-service review and denial.' [[chunk 199]]
Failure to submit Recommended Clinical Review for MP Criteria codes may lead to post-service review or denial if clinical criteria are not reviewed before service [[chunk 212]]

Note

Use the searchable PDF to locate codes and instructions

Use the searchable PDF (CTRL+F) to quickly locate procedure codes or descriptions in this document before submitting claims or prior authorization requests.

The document is a searchable PDF and instructs users to press CTRL+F to find a procedure code or description [[chunk 1]]

Prior Authorization

Check member contract for PA requirements on Unlisted codes

Verify member contract for prior authorization requirements for unlisted codes — many Unlisted entries state 'Prior Authorization may be required per contract agreement.'

Examples across specialties repeatedly note: 'Prior Authorization may be required per contract agreement' for unlisted codes (e.g., 22899, 38589) [[chunk 35]]
Head and neck/lymphatic unlisted codes (e.g., 38589, 38999) include PA-notes; providers should follow contract guidance [[chunk 74]]
Ophthalmology unlisted codes also reference contract-dependent prior authorization (e.g., 66999) [[chunk 128]]

Denial Risk

Non Covered codes — do not expect reimbursement

Do not submit claims for Non Covered codes expecting reimbursement; codes labeled 'Non Covered' are not benefits and are not subject to pre-service review.

Examples: 'Non Covered: Procedure/service not covered by the Plan: Not subject to pre-service review' for fertility codes 58321–58323 [[chunk 109]]
Multiple laboratory tests and other items are explicitly labeled Non Covered and will be denied if billed [[chunk 145]]
The document consistently marks Non Covered codes as not subject to pre-service review and not reimbursable [[chunk 163]]

Documentation Required

Provide Medical Policy–supporting documentation with Recommended Clinical Review

For MP Criteria codes, include documentation that satisfies the referenced Medical Policy Criteria when you submit the Recommended Clinical Review; documentation should support medical necessity per the policy.

The document instructs providers to 'submit documentation to support Recommended Clinical Review as specified by the Plan (clinical justification per Medical Policy Criteria)' for MP Criteria codes [[chunk 196]]
When a code is labeled MP Criteria the provider must submit the case for Recommended Clinical Review prior to claim submission to avoid post-service review [[chunk 195]]
Multiple MP Criteria entries reiterate that documentation supporting medical necessity should be provided with Recommended Clinical Review submissions [[chunk 252]]

Billing Rule

Unlisted code billing: submit supporting documentation and obtain PA when required

Unlisted procedure codes billed without adequate supporting documentation or required prior authorization may be subject to post-service review or denial.

Unlisted cardiac/vascular codes (e.g., 33999, 36299) note both MP Criteria and Unlisted flags; providers should supply documentation and PA when applicable [[chunk 56]]
The policy lists numerous unlisted CPTs and states that documentation and/or prior authorization may be required per contract and clinical review [[chunk 162]]
Provider action: submit clinical details when billing unlisted codes to avoid denials or delays [[chunk 35]]

Denial Risk

EIU codes are excluded from pre-service review and remain non‑reimbursable

Certain codes are explicitly designated EIU and are not subject to pre-service review; submitting these for prior authorization will not change their non‑reimbursed status.

The policy states EIU items are 'Procedure/service not reimbursed by the Plan' and 'Not subject to pre-service review' (examples throughout the list) [[chunk 203]]
Codes such as 0599T (fluorescence wound imaging) are EIU and noted as not reimbursed; pre-service review does not apply [[chunk 234]]
Multiple entries reiterate that EIU designation means the service will not be reimbursed regardless of pre-service submission [[chunk 220]]

Prior Authorization

Submit MP Criteria codes for Recommended Clinical Review to avoid post-service review

If a procedure is labeled 'MP Criteria' in the code list, submit a Recommended Clinical Review (predetermination) to avoid post-service review; many MP Criteria entries explicitly repeat this instruction.

A dedicated 'Recommended Clinical Review' group identifies codes that must be submitted for Recommended Clinical Review to avoid post-service review [[chunk 151]]
MP Criteria code groups (examples in multiple sections) state 'Submit for Recommended Clinical Review to avoid post-service review' [[chunk 155]]
Sectioned lists of MP Criteria codes reiterate that submission for Recommended Clinical Review is required to avoid post-service review [[chunk 165]]

When billing an Unlisted code, submit supporting clinical documentation and check contract-specific Prior Authorization requirements.

RiskUnlisted codes may trigger post-service review or denial if documentation or required prior authorization is not provided.

inv-232: EIU

DefinitionEIU (Experimental, Investigational and Unproven): Procedure/service designated as experimental, investigational, and/or unproven; these services are not reimbursed by the Plan.

Plan stanceEIU items are not subject to pre-service review and are excluded from reimbursement; consult the EIU/CPCP policy for details.

Denial riskClaims for EIU-designated procedures will be denied if billed since they are not reimbursed by the Plan.

inv-233: MP Criteria

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

ExamplesMultiple CPT codes across plastic/reconstructive categories are labeled MP Criteria — submission required per document guidance.

DocumentationProvide clinical documentation that addresses referenced Medical Policy Criteria when submitting Recommended Clinical Review.

inv-234: EIU

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

ImplicationProviders should not expect reimbursement for EIU-designated services; billing may result in denial.

ReferenceConsult the Plan's EIU / CPCP guidance for details and any exceptions noted in policy documents.

inv-235: Unlisted

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

Provider actionWhen using Unlisted codes (e.g., 33999, 36299, 37501), submit detailed clinical documentation and verify contract-specific PA requirements.

RiskFailure to obtain required prior authorization or adequate documentation may cause post-service review or denial.

inv-236: Unlisted

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

DocumentationSubmit supporting clinical documentation and justification of medical necessity when billing Unlisted procedures.

Prior AuthorizationPrior Authorization may be required per contract — verify payer instructions before service.

inv-237: EIU

DefinitionEIU: Procedure/service that is not reimbursed by the Plan per the EIU policy; not subject to pre-service review and referenced to a Clinical Payment and Coding Policy.

ExamplesDocument lists specific EIU-designated codes (e.g., 0599T, 0603T in excerpts) that are not reimbursed.

ActionDo not submit for pre-service reimbursement expectation; consult EIU/CPCP for guidance on clinical exceptions.

inv-238: EIU

DefinitionEIU: Procedure/service designated as experimental, investigational, or unproven; these services are not reimbursed by the Plan.

Denial consequenceClaims for EIU-designated services will be denied; pre-service review is not applicable for many EIU items.

ReferenceSee the Clinical Payment and Coding Policy (CPCP) EIU section for complete details and examples.

inv-239: Unlisted

DefinitionUnlisted: Unlisted procedures are not specifically defined or classified and may be subject to contract/clinical review; Prior Authorization may be required per contract agreement.

Provider guidanceSubmit clinical documentation and check contract PA requirements when billing Unlisted codes to reduce risk of denial.

ExamplesMany unlisted CPTs across specialties (e.g., 22899, 23929, 66999) are marked Unlisted in the document.

inv-240: MP Criteria / Recommended Clinical Review

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

Recommended actionProviders should submit MP Criteria codes for Recommended Clinical Review (predetermination) prior to claim submission when possible.

RationaleSubmission reduces the likelihood of post-service review and potential denial if Medical Policy Criteria are not met.

inv-241: MP Criteria

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

Clinical documentationWhen submitting MP Criteria items, include documentation that satisfies the referenced Medical Policy Criteria to support coverage.

TimingPre-service Recommended Clinical Review is recommended; lack of pre-service review may trigger post-service review.

inv-242: Unlisted

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

Provider actionProvide full clinical justification and check payer-specific prior authorization and documentation requirements for Unlisted codes.

Denial riskFailure to supply required documentation or PA may lead to post-service review or denial.

inv-243: Non Covered

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

ImplicationClaims billed with Non Covered codes will be denied — these are not benefits under the Plan.

ExamplesDocument lists Non Covered items (e.g., certain lab tests, acupuncture codes, fertility storage codes) — see code table for specifics.

inv-244: MP Criteria

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

ActionSubmit MP Criteria items for Recommended Clinical Review (predetermination) where indicated in the code list.

BenefitPre-service review helps determine if services meet Medical Policy Criteria and prevents unexpected denials.

inv-245: Unlisted

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

Provider noteUnlisted codes often require submission of clinical details describing the service performed; check payer guidance for required fields.

ExamplesMany Unlisted CPTs appear across specialties (e.g., 38589, 38999, 39499) — see code table for details.

inv-246: Non Covered

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

ConsequenceBilling Non Covered services will result in denial of payment; do not expect reimbursement under the Plan.

ExamplesDocument lists specific Non Covered codes (e.g., 92548, certain laboratory tests, acupuncture codes) — consult table.

inv-247: EIU

DefinitionEIU: Procedure/service that is not reimbursed by the Plan per the EIU policy; not subject to pre-service review and referenced to a Clinical Payment and Coding Policy.

Provider guidanceRefer to the CPCP EIU section for full context — EIU services are excluded from reimbursement.

ExamplesDocument flags many Category III/T and other codes as EIU (see code groups for specifics).

inv-248: Non Covered

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

ImplicationThese services will be denied if submitted for reimbursement; verify plan benefits before performing service.

ExamplesSeveral codes in the document are explicitly labeled Non Covered — review the code list for exact codes.

inv-249: Unlisted

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

DocumentationProvide clinical rationale and supporting records when submitting Unlisted codes to facilitate review.

Check contractPA requirements for Unlisted codes depend on the member's contract — verify before service.

inv-250: EIU

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

ActionDo not expect reimbursement for EIU-designated services; consult CPCP for any rare exceptions or research protocols.

Denial riskClaims for EIU services will be denied when submitted for reimbursement.

inv-251: MP Criteria

DefinitionMP Criteria: Procedure/service reviewed against Medical Policy Criteria; recommended clinical review submission to avoid post-service review.

Required stepSubmit MP Criteria codes for Recommended Clinical Review (predetermination) where indicated to reduce post-service denials.

Verify documentationInclude evidence that the service meets the Medical Policy Criteria when submitting for Recommended Clinical Review.

inv-252: EIU

DefinitionEIU: Procedure/service not reimbursed by the Plan (check EIU policy within the Clinical Payment and Coding Policy).

Provider noteEIU designation indicates exclusion from reimbursement and that pre-service review typically does not apply.

ExamplesMultiple codes across the list are labeled EIU — consult code table for specifics.

inv-253: MP Criteria

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

Provider actionSubmit MP Criteria items for predetermination/Recommended Clinical Review when possible.

RationaleThis administrative designation triggers utilization management processes tied to Medical Policy Criteria.

inv-254: EIU

DefinitionEIU: Designation indicating the procedure/service is treated as experimental, investigational, or unproven and is not reimbursed by the Plan.

Coverage impactEIU services are excluded from benefits and will be denied if billed.

ReferenceConsult the CPCP EIU section for policy context and any updates.

inv-255: MP Criteria / Recommended Clinical Review

DefinitionMP Criteria / Recommended Clinical Review: Designation indicating the procedure/service is reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review.

ActionWhen a code is labeled MP Criteria, submit for Recommended Clinical Review and include documentation addressing the applicable Medical Policy Criteria.

BenefitPre-service review helps determine coverage and reduces risk of post-service denials.