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CurrentBlue Cross Blue Shield - TexasPolicy N/A

Recommended Clinical Review and Non-Covered Procedure Code List (ASO)

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A code-level list and guidance describing procedure codes that are subject to recommended clinical review, medical necessity review, not covered, experimental/unproven, or unlisted for Blue Cross Blue Shield - Texas ASO plans; applicable to providers submitting claims or predeterminations.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review and Non-Covered Procedure Code List (ASO)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical 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 medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/1/2025codes effective on or before

200+procedure codes listed (approx.)

Multiplecode groupings

~20+codes labeled EIU / Non Covered

Coverage categories, definitions, and handling

Review categories and required action

Codes are categorized and reviewed as follows

Recommended Clinical Review (Predetermination): Procedures/services listed as 'MP Criteria' should be submitted for Recommended Clinical Review (Predetermination) to avoid post-service review.

Applies to procedures/services reviewed against Medical Policy Criteria.

Not Covered: Procedures/services listed as 'Non Covered' are not covered by the Plan and are not subject to pre-service review.

Entries marked 'Non Covered' will be denied if billed.

Experimental/Investigational/Unproven (EIU): Procedures/services listed as 'EIU' are considered experimental, investigational, and/or unproven and are not reimbursed by the Plan.

See EIU policy (Clinical Payment and Coding Policy) for details; EIU items are not subject to pre-service review.

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

Examples include unlisted codes such as 15999 and 17999; submit supporting documentation when requesting review.

Code group coverage logic

Coverage and management groupings reflected in the code list

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

Applies to many CPT codes listed (examples: 17107, 17108, 17360, 17380, 19105, 19300–19371, 29866–29916).

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

Applies to codes explicitly labeled EIU such as 17340, 20560–20561, 20985, 30468–30469; check EIU/CPCP for policy details.

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

Applies to unlisted codes like 17999, 19499, 20999, 29999, etc.; providers should submit detailed documentation.

Non Covered:

Coverage designations and required administrative actions

Coverage designations by code group and required action

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

Examples include arthroscopy grafting/transplantation and many device/procedure codes.

EIU (Excluded / Not Reimbursed): Codes labeled 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; claims for these codes will likely be denied.

Examples include certain nasal valve repairs, PRP, and other codes explicitly marked EIU in the list.

Unlisted codes: Unlisted procedure codes are not specifically defined and may be subject to contract/clinical review; Prior Authorization may be required per contract.

When submitting unlisted codes include a full procedure description and supporting clinical documentation.

Coverage group rules

Coverage/authorization guidance by code group

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

Applies to codes labeled 'MP Criteria' throughout the list (e.g., many GI, bariatric, and ablation codes).

EIU (Excluded/Not reimbursed) codes: Procedure/service not reimbursed by the Plan; not subject to pre-service review. Providers should consult the EIU policy (CPCP) before billing.

Applies to entries explicitly marked EIU (e.g., optical endomicroscopy codes).

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

Prior Authorization may be required for unlisted entries; include detailed documentation when requesting review.

Plan-level designation and actions

Designation and required action for codes in this extract

MP Criteria: When a code is labeled 'MP Criteria' the procedure/service is reviewed against the applicable Medical Policy criteria and providers should submit for Recommended Clinical Review to avoid post-service review.

Examples in this extract: 97037, 0071T, 0072T, 0200T, 0253T.

EIU (Not Reimbursed): When a code is labeled EIU the procedure/service is not reimbursed by the Plan and is not subject to pre-service review; billing these codes will likely result in nonpayment.

Examples in this extract: 97610, 0063U, 0226U, 0232T.

Unlisted / Prior Auth Possible: Unlisted codes may be subject to contract or clinical review and Prior Authorization may be required per contract; submit documentation specifying type/time/description.

Examples: 97039, 97139, 17999, 19499.

Non Covered:

Code-level coverage categories

Coverage and review categories applied to listed temporary codes

EIU (Procedure/service not reimbursed): Codes labeled 'EIU' are categorized as procedures/services not reimbursed by the Plan and are not subject to pre-service review; see EIU/CPCP policy.

Examples among temporary/Category III codes: 0772T–0774T, 0776T–0779T, many other T-codes marked EIU.

MP Criteria (Requires 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 neurostimulation, leadless pacemaker procedures, programming and other device-related T-codes.

Non Covered: Codes labeled 'Non Covered' are not covered by the Plan (e.g., 0811T, 0812T) and are not subject to pre-service review.

Non Covered entries will be denied if billed.

Administrative handling categories

Coverage/handling categories in this extract

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

Applies to many codes listed (examples: 0872T, 0873T, 0874T, 0875T, and numerous A20xx/A203x entries).

EIU: Procedure/service not reimbursed by the Plan; not subject to pre-service review. Providers should check the EIU policy (CPCP) before billing.

Many A‑codes and selected CPTs in the wound matrix and device groups are marked EIU (e.g., A2001–A2013).

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

Examples include transportation ancillary codes and specific supply codes (e.g., A0888).

Unlisted services may be subject to contract/clinical review; Prior Authorization may be required per contract.

Procedures and services that the document labels as Non Covered are explicitly not covered by the Plan and are not subject to pre-service review. When a code is grouped as Non Covered, submission for predetermination will not change reimbursement status and claims for those codes are expected to be denied as not covered.

The listing includes specific codes designated Non Covered; examples called out in the extract include 21032 (Excision of maxillary torus palatinus) and 21248 (Reconstruction of mandible or maxilla, endosteal implant; partial). These codes are shown in the file with the administrative label Non Covered: Procedure/service not covered by the Plan: Not subject to pre-service review.

Codes and procedures categorized as EIU (Experimental/Investigational/Unproven) are described in the file as not reimbursed by the Plan. The document states that EIU entries are not subject to pre-service review and providers should consult the EIU/CPCP policy for details.

The document repeatedly labels specific procedure codes as EIU, clarifying that these procedures/services are not reimbursed by the Plan and are not subject to pre-service review. The guidance advises checking the EIU policy within the Clinical Payment and Coding Policy (CPCP) for additional details.

Several codes in the extract are explicitly marked EIU and the file describes these entries as procedure/service not reimbursed by the Plan. Examples listed in the document include diagnostic/laboratory and gastroenterology related codes that are labeled EIU and therefore excluded from reimbursement.

Reproductive procedures associated with infertility and assisted reproduction are shown as Non Covered in this extract. Specific examples include 58321 (artificial insemination; intra-cervical), 58322 (artificial insemination; intra-uterine), 58323 (sperm washing for artificial insemination), and 58750 (tubotubal anastomosis). These codes are listed as Non Covered: Procedure/service not covered by the Plan: Not subject to pre-service review.

The list includes several specialized laboratory and diagnostic tests that are classified as EIU. Examples called out in the document include 82523 (collagen cross links), 83695 (lipoprotein [a]), 83698 (Lp-PLA2), and 83704 (lipoprotein particle quantitation). These are documented as EIU: Procedure/service not reimbursed by the Plan and not subject to pre-service review.

A number of necropsy/autopsy procedures and reproductive cryopreservation/storage/thawing services are listed as Non Covered. The extract explicitly lists the 88000 series (necropsy/autopsy) and reproductive cryopreservation codes such as 89258–89356 as Non Covered: Procedure/service not covered by the Plan; these services are not subject to pre-service review.

Throughout the extract multiple Category III and other newer codes are labeled EIU and the policy language reiterates that EIU entries indicate a procedure/service not reimbursed by the Plan. The file repeatedly states EIU items are not subject to pre-service review and refers providers to the EIU/CPCP for reimbursement details.

Many entries in the Category III/tentative code sections are designated EIU in the extract and are described as procedure/service not reimbursed by the Plan. The document provides many code examples across these chunks where the EIU label indicates the Plan will not reimburse those services.

The extract identifies specific codes with an administrative exclusion status. For example, 97610 (low frequency, non-contact non-thermal ultrasound for wound care) is labeled EIU and described as not reimbursed by the Plan. Similarly, several acupuncture-related codes (e.g., 97810) are marked Non Covered in this segment.

Items annotated in the file as EIU: Procedure/service not reimbursed by the Plan: Not subject to pre-service review are excluded from Plan reimbursement. The document repeatedly flags such codes and notes provider submissions for these services would not alter reimbursement status.

Codes marked in the extract as EIU: Procedure/service not reimbursed by the Plan are treated as excluded from reimbursement and are not subject to pre-service review. The policy highlights that providers should check the EIU/CPCP for additional guidance on these not-reimbursed entries.

Multiple Category III codes included in the document are explicitly designated EIU and annotated as Procedure/service not reimbursed by the Plan. The file groups these temporary codes administratively to indicate they are not covered and not eligible for predetermination review.

The extract explicitly lists 0811T and 0812T (remote multi-day complex uroflowmetry set‑up and device supply/report) as Non Covered. The entries state these services are not covered by the Plan and are not subject to pre‑service review.

Across the Category III and novel-technology code excerpts, many codes are labeled EIU with the consistent statement that the procedure/service is not reimbursed by the Plan. The document repeats this designation to clarify administrative non‑coverage for these entries.

Codes explicitly labeled in the extract as Non Covered or EIU are not reimbursed by the Plan and therefore excluded from coverage. Examples include ambulance/transportation A‑codes (e.g., A0080–A0210) and various A20xx wound matrix codes that are shown with an EIU or Non Covered designation.

The policy excerpt lists 17340 (cryotherapy for acne) with the administrative label EIU, explicitly stating the service is not reimbursed by the Plan and therefore not covered when billed.

Necropsy and autopsy procedures in the 88000 series are listed as Non Covered in the extract. The file marks these codes as procedure/service not covered by the Plan and thus not reimbursable.

The extract contains additional examples of codes explicitly labeled Non Covered (e.g., 94452, 94453) and reiterates that services with this label are not covered by the Plan and at risk for denial if billed.

The code 97610 is specifically identified in the document as EIU — the policy states EIU: Procedure/service not reimbursed by the Plan, indicating that claims using this code are not eligible for Plan reimbursement.

The extract consistently treats codes designated EIU as not reimbursed by the Plan and notes these codes are not subject to pre-service review. Providers should consult the EIU/CPCP for the Plan's formal stance and guidance on these exclusions.

As noted elsewhere, 0811T and 0812T are shown under the Non Covered label in the extract; the entries state these services are not covered by the Plan and not subject to pre-service review.

This extract does not present detailed clinical 'not medically necessary' statements for conditions; instead it uses administrative classifications — MP Criteria, EIU, Non Covered, and Unlisted — to indicate how listed codes are handled for review and reimbursement. See the document definitions and coverage nodes for the administrative meaning of each label.

Code tables and grouped CPT/HCPCS listings

MP Criteria / Reviewed codes (sample)CPT

00797	Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity.
11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less.
11951	Subcutaneous injection of material (eg, collagen); 1.1 to 5.0 cc filling.
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc.
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc.
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).

Skin substitute, grafting, and related CPTsCPT

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.
15272	Application of skin substitute to trunk; arms, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area.
15273	Application of skin substitute graft to trunk, arms, legs, total wound surface area >= 100 sq cm; first 100 sq cm wound surface area.
15274	Application of skin substitute to trunk, arms, legs, total wound surface area >= 100 sq cm; each additional 100 sq cm wound surface area.
15275	Application of skin substitute to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet; and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less.
15276	Application of skin substitute to face, scalp... total wound surface area up to 100 sq cm; each additional 25 sq cm.
15277	Application of skin substitute to face, scalp... total wound surface area >= 100 sq cm; first 100 sq cm.
15278	Application of skin substitute to face, scalp... total wound surface area >= 100 sq cm; each additional 100 sq cm.
15758	Free fascial with microvascular anastomosis flap.
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia).

1–10 of 12

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Additional CPTs (plastic/reconstructive and related)CPT

15775	Punch for hair transplant; 1 to 15 punch grafts.
15776	Punch graft for hair transplant; more than 15 punch grafts.
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.

1–10 of 43

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EIU / Not reimbursed exampleCPTNot Covered

17340

Cryotherapy (CO2 slush, liquid N2) for acne.

Mixed dermatologic procedure codesCPT

17107	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm
17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
17340	Cryotherapy (CO2 slush, liquid N2) for acne
17360	Chemical exfoliation for acne (eg, acne paste, acid)

Breast and skin proceduresCPT

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

Breast reconstruction/implant codesCPT

19328	Removal of intact breast 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 day from mastectomy
19350	Nipple/areola reconstruction
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s)
19370	Revision of peri-implant capsule, breast; including capsulotomy, capsulorrhaphy, and/or partial capsulectomy
19371	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
19499	Unlisted procedure, breast

Musculoskeletal and related proceduresCPT

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

Craniofacial/maxillofacial codesCPT

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
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

1–10 of 12

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Spine and related proceduresCPT

21299	Unlisted craniofacial and maxillofacial procedure
21499	Unlisted musculoskeletal procedure, head
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, L5-S1

Miscellaneous surgical, arthroscopy, spine, and ENT procedure codesCPT

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, or removal of thoracic vertebral body tethering
22867	Insertion of interlaminar/interspinous stabilization device with open decompression, lumbar; single level
22868	Insertion of interlaminar/interspinous stabilization device with open decompression, lumbar; second level
22869	Insertion of interlaminar/interspinous stabilization device without open decompression or fusion, lumbar; single level
22870	Insertion of interlaminar/interspinous stabilization device without open decompression or fusion, lumbar; second level
22899	Unlisted procedure, spine
22999	Unlisted procedure, abdomen, musculoskeletal system
23929	Unlisted procedure, shoulder

1–10 of 37

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MP Criteria / Recommended Clinical ReviewCPTCovered

29866	Arthroscopy, knee, surgical; osteochondral allograft
29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)
29868	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal)
29914	Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

Mixed MP Criteria / UnlistedCPT

29915	Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
29916	Arthroscopy, hip, surgical; with labral repair
29999	Unlisted procedure, arthroscopy

EIU / Unlisted / MP Criteria mixCPTNot Covered

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
31299	Unlisted procedure, accessory sinuses
31599	Unlisted procedure, larynx

MP Criteria / EIU mixed bronchial proceduresCPT

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... each additional lobe
31660	Bronchoscopy... with bronchial thermoplasty, 1 lobe
31661	Bronchoscopy... with bronchial thermoplasty, 2 or more lobes

Pulmonary ablation / UnlistedCPT

32994	Ablation therapy... pulmonary tumor(s)... unilateral; cryoablation
32998	Ablation therapy... pulmonary tumor(s)... unilateral; radiofrequency
32999	Unlisted procedure, lungs and pleura

Cardiac device procedures (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 pacing electrode, cardiac venous insertion of implantable defibrillator or pacemaker pulse generator

Phrenic nerve stimulator proceduresCPTNot Covered

33276	Insertion of phrenic nerve stimulator system
33277	Insertion of phrenic nerve stimulator transvenous sensing lead
33278	Removal of phrenic nerve stimulator; system
33279	Removal of phrenic nerve stimulator; transvenous stimulation or sensing lead(s) only
33280	Removal of phrenic nerve stimulator; pulse generator only
33281	Repositioning of phrenic nerve stimulator transvenous lead(s)

Cardiac monitoring/valve proceduresCPT

33285	Insertion, subcutaneous cardiac rhythm monitor; including programming
33287	Removal and replacement of phrenic nerve stimulator; pulse generator
33288	Removal and replacement of phrenic nerve stimulator; transvenous stimulation or sensing lead(s)
33289	Transcatheter implantation of wireless pulmonary artery pressure sensor
33361	Transcatheter aortic valve replacement (TAVR/TAVI); percutaneous femoral artery approach
33362	TAVR; pen femoral artery approach

TAVR procedural codesCPTCovered

33363	TAVR; open axillary artery approach
33364	TAVR; open iliac artery approach
33365	TAVR; transaortic approach
33366	TAVR; transapical exposure
33367	TAVR; cardiopulmonary bypass support with percutaneous peripheral cannulation (add-on)
33368	TAVR; cardiopulmonary bypass support with open peripheral cannulation (add-on)
33369	TAVR; cardiopulmonary bypass support with central arterial and venous cannulation (add-on)

Transcatheter valve proceduresCPTCovered

33418	Transcatheter mitral valve repair, percutaneous approach; initial prosthesis
33477	Transcatheter pulmonary valve implantation, percutaneous approach

Cardiac/vascular unlisted and artificial heartCPT

33927	Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy
33928	Removal and replacement of total replacement heart system (artificial heart)
33999	Unlisted procedure, cardiac surgery
36299	Unlisted procedure, vascular injection

Venous injection/ablation codesCPT

36465	Injection of non-compounded foam sclerosant... single incompetent extremity truncal vein
36466	Injection of non-compounded foam sclerosant... multiple incompetent truncal veins, same leg
36468	Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)
36471	Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
36473	Endovenous ablation therapy... percutaneous, mechanochemical; first vein treated
36474	Endovenous ablation therapy... percutaneous, mechanochemical; subsequent vein(s) treated
36475	Endovenous ablation therapy... percutaneous, radiofrequency; first vein treated
36476	Endovenous ablation therapy... percutaneous, radiofrequency; subsequent vein(s) treated
36478	Endovenous ablation therapy... percutaneous, laser; first vein treated

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Endovenous ablation codesCPTCovered

36474	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring; percutaneous, radiofrequency; first vein
36475	Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring; percutaneous, radiofrequency; first vein post-service review
36476	Endovenous ablation therapy ... radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites
36478	Endovenous ablation therapy ... percutaneous, laser; first vein treated
36479	Endovenous ablation therapy ... percutaneous, laser; subsequent vein(s) treated
36482	Endovenous ablation therapy ... transcatheter delivery of a chemical adhesive; percutaneous; first vein treated
36483	Endovenous ablation therapy ... transcatheter delivery of a chemical adhesive; subsequent vein(s) treated

Vascular access and photopheresisCPT

36522	Photopheresis, extracorporeal
36836	Percutaneous arteriovenous fistula creation, upper extremity and peripheral vein, including maturation procedures
36837	Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of peripheral artery and peripheral vein

Embolization and stent codesCPTCovered

37215	Transcatheter placement of intravascular stent(s), cervical carotid artery; with distal embolic protection
37216	Transcatheter placement of intravascular stent(s), cervical carotid artery; without distal embolic protection
37217	Transcatheter placement of intravascular stent(s), intrathoracic common carotid or innominate artery by retrograde treatment
37218	Transcatheter placement of intravascular stent(s), intrathoracic common carotid or innominate artery, antegrade approach
37241	Vascular embolization or occlusion, venous, other than hemorrhage
37242	Vascular embolization or occlusion, arterial, other than hemorrhage or tumor
37243	Vascular embolization or occlusion, for tumors, organ ischemia, or infarction
37244	Vascular embolization or occlusion, for arterial or venous hemorrhage or lymphatic extravasation

Varicose vein and saphenous surgeryCPTCovered

37500	Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)
37501	Unlisted vascular endoscopy procedure
37700	Ligation and division of long saphenous vein at saphenofemoral junction
37718	Ligation, division, and stripping, short saphenous vein
37722	Ligation, division, and stripping, long (greater) saphenous veins
37735	Ligation and division and complete stripping ... with radical excision of ulcer and skin graft
37760	Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, 1 leg
37761	Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, 1 leg
37765	Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
37766	Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

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Hematopoietic progenitor cell and transplant preparationCPTCovered

38129	Unlisted laparoscopy procedure, spleen
38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing
38209	Transplant preparation of hematopoietic progenitor cells; thawing with washing
38210	Transplant preparation of hematopoietic progenitor cells; specific cell depletion, T-cell depletion
38211	Transplant preparation of HPC; tumor cell depletion
38212	Transplant preparation of HPC; red blood cell removal
38213	Transplant preparation of HPC; platelet depletion

1–10 of 16

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Head and neck / lymphatic proceduresCPTCovered

38308	Lymphangiotomy or other operations on lymphatic channels
38589	Unlisted laparoscopy procedure, lymphatic system
38999	Unlisted procedure, hemic or lymphatic system
39499	Unlisted procedure, mediastinum
39599	Unlisted procedure, diaphragm
40799	Unlisted procedure, lips
40899	Unlisted procedure, vestibule of mouth
41120	Glossectomy; less than one-half tongue
41512	Tongue base suspension, permanent suture technique
41530	Submucosal ablation of the tongue base, radiofrequency

1–10 of 11

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Oral, pharyngeal, and esophageal proceduresCPT

41872	Gingivoplasty, each quadrant
41899	Unlisted procedure, dentoalveolar structures
42140	Uvulectomy, excision of uvula
42145	Palatopharyngoplasty (eg, uvulopalatopharyngoplasty)
42299	Unlisted procedure, palate, uvula
42699	Unlisted procedure, salivary glands or ducts
42950	Pharyngoplasty (plastic or reconstructive operation on pharynx)
42999	Unlisted procedure, pharynx, adenoids, or tonsils
43206	Esophagoscopy, flexible, transoral; with optical endomicroscopy
43236	Esophagogastroduodenoscopy, flexible; with directed submucosal injection(s), any substance

1–10 of 15

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Procedure CPT/Unlisted codes and group descriptionsCPT | mixed

42999	Code listed with 'Authorization may be required per contract agreement.'
43206	Esophagoscopy, flexible, transoral; with optical endomicroscopy (ElU: not reimbursed; not subject to pre-service review)
43236	Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance. (MP Criteria)
43252	Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy (ElU)
43257	Esophagogastroduodenoscopy; with delivery of thermal energy to LES/gastric cardia for GERD (MP Criteria)
43284	Laparoscopy, esophageal sphincter augmentation device placement (MP Criteria)
43289	Unlisted laparoscopy procedure, esophagus (MP Criteria / Unlisted)
43290	Esophagogastroduodenoscopy; with deployment of intragastric bariatric balloon (EIU)
43291	Esophagogastroduodenoscopy; with removal of intragastric bariatric balloon(s) (EIU)
43499	Unlisted procedure, esophagus (Unlisted)

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Prior authorization, submission, and documentation instructions

Prior Authorization

Prior Authorization may be required

Some unlisted procedure codes (for example 15999, 17999) may require prior authorization per the member's contract; highlighted services in these code groups may require prior auth.

Examples called out as 'Unlisted' may be subject to contract/clinical review and Prior Authorization per contract agreement (see 15999, 17999).

Prior Authorization

Prior Authorization may be required for Unlisted codes

Unlisted procedure codes are identified as 'Unlisted' and may be subject to contract or clinical review; prior authorization may be required per contract.

Examples: codes listed as Unlisted include 17999 and 19499; providers should check contract requirements before billing.

Document purpose and scope

BACKGROUND: This file groups procedure codes by administrative review category to guide provider submission and utilization management. The categories include MP Criteria (procedures reviewed against Medical Policy Criteria and recommended for pre-service clinical review), EIU (Experimental/Investigational/Unproven procedures that are not reimbursed by the Plan), Non Covered (procedures not covered and not subject to pre-service review), and Unlisted (procedures not specifically defined that may require contract or clinical review and prior authorization per contract).

Key term definitions used in this list

Experimental, Investigational, Unproven (EIU)

DefinitionProcedures/services for which the Medical Policy Coverage statement indicates they are experimental, investigational, and/or unproven in all situations.

Reimbursement stanceEIU-classified services are described as not reimbursed by the Plan in this document.

Pre-service reviewEIU entries are generally not subject to pre-service (predetermination) review; providers should check the EIU/CPCP for policy details.

Unlisted or Undefined

DefinitionProcedures/services not specifically defined or classified; may be subject to contract or clinical review.

Prior authorizationUnlisted/undefined codes may require prior authorization per contract agreement.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review and Non-Covered Procedure Code List (ASO)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical 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 medical necessity review.

SourceLink

On This Page

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

Applies where 'Non Covered' is explicitly stated (example: 21032).

Codes explicitly listed as Non Covered are not covered by the Plan and are not subject to pre-service review.

Examples in this extract: selected reproductive, necropsy, and transportation ancillary codes.

Example: A0999 and other 'Unlisted' ambulance/transport codes; include description and justification when submitting for review.

Wound surface area thresholds for skin substitute codes

15271-15272 (trunk/limbs, up to 100 sq cm)First 25 sq cm (15271) with each additional 25 sq cm billed with 15272; up to 100 sq cm total for face/trunk/limbs variants

15273-15274 (trunk/limbs, >=100 sq cm)First 100 sq cm (15273) with each additional 100 sq cm billed with 15274; used when total wound surface area >= 100 sq cm

15275-15278 (face/critical sites)For face/scalp/eyelids/mouth/neck/ears/orbits/genitalia/hands/feet/multiple digits: up to 100 sq cm first 25 sq cm (15275), additional 25 sq cm (15276), first 100 sq cm for >=100 sq cm (15277), each additional 100 sq cm (15278); infants/children may use percent body area equivalents (1% increments)

Infant/child sizing noteWhen noted, wound surface area may be reported as percent body area (1% increments) — e.g., 1% body area = first 100 sq cm equivalence per code descriptions

Age for VR procedural dissociation initial service

Initial VR procedural dissociation (0773T)Defined for patient age 5 years or older for the initial 15 minutes when provided by a different clinician than the primary service provider

Additional intraservice time (0772T, 0774T)Each additional 15 minutes is billed separately (0772T when by same provider; 0774T when by other provider)

EIU classificationThese VR procedural dissociation codes (0772T–0774T) are designated EIU or listed with age thresholds and are not reimbursed as indicated in the code group descriptions

Unlisted codes may require prior authorization

Unlisted procedure codes are noted as possibly subject to contract/clinical review and prior authorization may be required per contract agreement.

Examples of Unlisted entries: 29999, 30999, 31299; obtain prior authorization when required by contract.

Prior Authorization

Prior Authorization for Unlisted Codes

Prior authorization may be required per contract for unlisted procedures or services not specifically defined or classified; submit per contract requirements.

Providers should submit unlisted procedure requests and supporting documentation for recommended clinical review or prior authorization where the contract requires it.

Prior Authorization

Prior authorization and recommended clinical review

Many codes labeled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review (predetermination) to avoid post-service review and potential denial.

MP Criteria entries require pre-service submission for Recommended Clinical Review when indicated.

Prior Authorization

Prior Authorization may be required for unlisted codes

Unlisted procedures and certain unclassified codes may require prior authorization per contract; providers should obtain prior authorization where indicated to avoid post-service review.

Examples: 54699, 55559, 58578, 58579, 59897, 59899 — check contract for PA requirements.

Prior Authorization

Prior authorization for unlisted procedures

Prior authorization may be required per contract agreement for unlisted procedures or services not specifically defined or classified.

Unlisted nervous system and ophthalmology unlisted codes (e.g., 64999, 66999, 67299, 67399) are flagged as potentially requiring PA per contract.

Prior Authorization

Prior authorization / MP review

Some services are reviewed against Medical Policy Criteria or may require prior authorization per contract; submit for recommended clinical review to avoid post-service review.

Examples: Select immunology/therapy codes (86353, 90378) and audiology/programming codes (92622, 92623) may trigger MP review or PA.

Prior Authorization

Unlisted codes may need prior auth

Unlisted procedures may require prior authorization per contract agreement and are subject to clinical/contract review.

Examples of unlisted lab and microbiology codes: 84999, 85999, 86849, 87797-87799, 87899 — include detailed procedure description when submitting.

Prior Authorization

Prior authorization for unlisted procedures

Prior authorization may be required per contract agreement for unlisted or not specifically defined procedures; submit per contract.

Unlisted otorhinolaryngological and cardiovascular service codes (e.g., 92700, 93799, 93998) may require PA per contract.

Prior Authorization

Prior Authorization may be required

Certain unlisted or undefined procedure codes are noted as 'may be subject to contract/clinical review' and 'Prior Authorization may be required per contract agreement.'

Examples include 97039, 97139, 97799, 99050 — confirm PA requirements with the member's contract.

Prior Authorization

MP Criteria: recommended pre-service review

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

Submit MP Criteria services as pre-service Recommended Clinical Review to reduce risk of post-service denial.

Prior Authorization

Recommended Clinical Review for MP Criteria codes

Recommended Clinical Review (pre-service submission) is advised for codes listed as 'MP Criteria' to avoid post-service review and potential denial.

Providers should include clinical documentation supporting the Medical Policy Criteria when submitting for Recommended Clinical Review.

Prior Authorization

Recommended clinical review for MP Criteria codes

These Category III codes are reviewed against Medical Policy Criteria and should be submitted for recommended clinical review (pre-service submission recommended to avoid post-service review).

Examples: 0614T, 0632T, 0643T, 0645T, 0659T — submit for Recommended Clinical Review.

Denial Risk

EIU — not reimbursed codes (check EIU policy)

Many Category III codes in this excerpt are designated EIU: procedure/service not reimbursed by the Plan; these are not subject to pre-service review but providers should check the EIU policy for details.

EIU examples include 0602T, 0603T, and multiple Category III entries — billing these may result in nonpayment.

Prior Authorization

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 0784T–0789T and other neurostimulation Category III entries — submit pre-service when possible.

Prior Authorization

Submit MP Criteria codes for Recommended Clinical Review

Codes marked 'MP Criteria' require submission for Recommended Clinical Review (pre-service review recommended) to avoid post-service review; prior authorization may be required per contract for unlisted or MP Criteria codes.

Examples: 0872T–0875T and many A20xx/A203x items — submit documentation and request Recommended Clinical Review where applicable.

Step Therapy

(no step therapy requirements specified)

No step therapy requirements are specified in this document excerpt.

Note

Searchable list and submission guidance

The file is a searchable PDF; providers should search by procedure code or description and submit for Recommended Clinical Review (predetermination) to avoid post-service review.

Use CTRL+F in the searchable PDF to locate codes and descriptions prior to submission.

Documentation Required

Documentation for MP Criteria

When a code is listed as 'MP Criteria', submit documentation for Recommended Clinical Review to avoid post-service review.

Include clinical documentation demonstrating how the service meets the referenced Medical Policy Criteria.

Documentation Required

Recommended Clinical Review

Submit for recommended clinical review documentation for codes with 'MP Criteria' to avoid post-service review.

Pre-service Recommended Clinical Review is advised for MP Criteria entries to reduce risk of post-service denial.

Documentation Required

Unlisted code documentation/PA note

Unlisted procedure codes are identified as 'Unlisted' and noted as possibly subject to contract/clinical review; prior authorization may be required per contract agreement.

When billing Unlisted codes, include a detailed procedure description and justification for medical necessity.

Documentation Required

Documentation expectations

When submitting codes flagged 'MP Criteria', include clinical documentation to meet Medical Policy Criteria and consider Recommended Clinical Review to avoid post-service review.

Documentation should specifically address the Medical Policy criteria referenced for the CPT code.

Documentation Required

Submit for Recommended Clinical Review

For codes designated MP Criteria, submit for Recommended Clinical Review to avoid post-service review; documentation should support medical necessity per the referenced Medical Policy Criteria.

Examples: 0872T–0875T and related entries — include operative notes, indication, and prior conservative therapy as applicable.

Documentation Required

Recommended Clinical Review

For codes with 'MP Criteria' designation, submit for Recommended Clinical Review (pre-service) to avoid post-service review.

Submitting pre-service reduces the risk of retrospective medical necessity review.

Documentation Required

Submit supporting clinical documentation

When codes are designated MP Criteria, submit clinical documentation for Recommended Clinical Review to avoid post-service review.

Include relevant clinical notes, imaging, prior treatments, and rationale tying to Medical Policy criteria.

Documentation Required

Documentation for unlisted codes

Unlisted codes may be subject to contract/clinical review; prior authorization may be required per contract — submit supporting documentation as required for review.

Examples of Unlisted codes flagged include 92700, 93799, 93998 — provide full description and justification when submitting.

Documentation Required

Unlisted codes may require documentation/prior authorization

Unlisted codes may be subject to contract/clinical review; prior authorization may be required per contract — submit supporting documentation as required for review.

When PA is required, include detailed procedural description, CPT rationale, and clinical indication.

Documentation Required

MP Criteria — submit clinical documentation

For codes with MP Criteria (e.g., 97037) submit for Recommended Clinical Review to avoid post-service review; documentation should support medical policy criteria.

Example: 97037 is MP Criteria — include clinical rationale that meets the referenced policy when submitting.

Documentation Required

Unlisted / Supply documentation

Unlisted codes note 'specify type' or list supplies/materials; documentation must specify procedure details or items supplied.

Examples: supply A-codes and unlisted modality codes should include item description, quantity, and clinical necessity.

Documentation Required

Submit for Recommended Clinical Review

For codes with 'MP Criteria' designation, submit for Recommended Clinical Review (pre-service) to avoid post-service review.

Pre-service submission is recommended for MP Criteria codes to prevent retrospective denials.

Documentation Required

Documentation for MP Criteria submissions

When submitting codes flagged 'MP Criteria', include clinical documentation to meet Medical Policy Criteria and consider Recommended Clinical Review to avoid post-service review.

Attach operative reports, imaging, and any conservative treatment records that demonstrate criteria are met.

Documentation Required

Documentation for MP Criteria codes

When codes are designated MP Criteria, submit clinical documentation for Recommended Clinical Review to avoid post-service review.

Specific Category III MP Criteria examples: 0614T, 0632T, 0643T — include procedure notes and policy cross-reference.

Documentation Required

Documentation for neurostimulation procedures

Documentation for neurostimulation procedures billed as MP Criteria should include clinical documentation per the Medical Policy Criteria to support medical necessity and avoid post-service review.

Include device details, indication, prior therapies, and programming/analysis reports as applicable.

Denial Risk

Recommended Clinical Review advised

Recommended Clinical Review (pre-service) is advised for codes listed as 'MP Criteria' to avoid post-service review; failure to submit may result in a post-service medical necessity review and potential denial.

Failure to obtain Recommended Clinical Review may trigger retrospective medical necessity review.

Prior Authorization

Submit MP Criteria services for clinical review

Services grouped as 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review; failure to submit may trigger post-service denial or clinical review.

Submitting MP Criteria services pre-service reduces the risk of denial for not meeting policy criteria.

Denial Risk

EIU-coded procedures not reimbursed

Procedures labeled 'EIU' (not reimbursed by the Plan) are not reimbursed and would be denied if billed.

Examples: EIU-designated procedures include many Category III and novel technology codes; charges for these will likely be denied.

Prior Authorization

MP Criteria review triggers

Procedures/services designated 'MP Criteria' are reviewed against Medical Policy Criteria; submit for recommended clinical review to avoid post-service review.

Examples include arthroscopy grafting and hip procedures (29866–29868, 29914–29916) — submit pre-service when appropriate.

Denial Risk

EIU (Excluded/Not Reimbursed) triggers

Procedures/services designated 'EIU' are not reimbursed by the Plan and are not subject to pre-service review; these entries indicate services that will not be paid.

Check the EIU/CPCP policy for further guidance before performing or billing EIU-designated services.

Denial Risk

Unlisted code risks

Unlisted procedure codes may be subject to contract/clinical review and prior authorization may be required per contract agreement.

Examples: 29999 and many other unlisted arthroscopy entries — include detailed descriptions and request PA if required.

Prior Authorization

MP Criteria review expectation

Procedures grouped as 'MP Criteria' are reviewed against Medical Policy Criteria; providers are instructed to submit for Recommended Clinical Review to avoid post-service review.

Denial Risk

EIU (not reimbursed) notification

Procedures grouped as 'EIU' may be not reimbursed by the Plan and are not subject to pre-service review; check EIU policy for reimbursement status.

Examples: 36836–36837 (percutaneous AV fistula creation) labeled EIU — billing may be denied.

Prior Authorization

Submission and review triggers

Procedures classified as MP Criteria are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review; Unlisted codes may be subject to contract/clinical review and Prior Authorization may be required per contract.

When a code is MP Criteria, submit pre-service documentation; when Unlisted, include detailed descriptions and request PA if contract requires it.

Prior Authorization

MP Criteria review required

Procedures/services reviewed against Medical Policy Criteria (MP Criteria) are subject to recommended clinical review to avoid post-service review; failure to submit for review may result in post-service review or denial.

Example: penile/testicular prosthesis codes (54400–54416) are MP Criteria — submit pre-service documentation.

Denial Risk

Unlisted code prior auth risk

Unlisted procedures may be subject to contract/clinical review and Prior Authorization may be required per contract agreement; submitting without required prior authorization may trigger denial.

Examples: 93228, 93229, 93580 — verify PA requirements and submit supporting documentation.

Denial Risk

Unlisted codes may require prior authorization

Unlisted procedures or codes noted as 'Unlisted' may be subject to contract/clinical review and prior authorization may be required per contract agreement, which can trigger denial if not obtained.

Codes listed as Unlisted (e.g., 64999, 66999) often note prior authorization may be required — follow contract rules.

Denial Risk

Non Covered services

Procedure/service classified as 'Non Covered' (e.g., reproductive cryopreservation/storage/thawing codes) are not reimbursed by the Plan and will be denied if billed.

Examples: 89258–89356 series for cryopreservation and storage are Non Covered and not payable.

Denial Risk

EIU (not reimbursed)

Procedure/service classified as 'EIU' (Experimental/Investigational/Unreimbursed) are not reimbursed by the Plan and may be denied if submitted for payment.

Examples: many specialized lab tests and novel therapies flagged EIU will not be paid; confirm before billing.

Denial Risk

Medical Policy (MP) review required

Procedure/service classified as 'MP Criteria' require review against Medical Policy Criteria and may be denied if criteria are not met.

Failure to provide requested documentation supporting Medical Policy criteria may result in denial.

Prior Authorization

Submit MP Criteria codes for clinical review

Procedures labeled 'MP Criteria' are reviewed against Medical Policy Criteria; submit for Recommended Clinical Review to avoid post-service review (i.e., risk of denial if not submitted).

Specific examples of MP Criteria codes are provided — submit pre-service with supporting clinical evidence.

Denial Risk

EIU / Not Reimbursed

97610 is categorized EIU: Procedure/service not reimbursed by the Plan and is not subject to pre-service review — using this code may result in nonpayment.

97610 (low-frequency non-contact ultrasound for wound care) is EIU and not reimbursed.

Denial Risk

Non Covered Codes

99071 and 99080 are listed as Non Covered in this extract and thus are at risk for denial if billed to the Plan.

99071 (educational supplies) and 99080 (special reports) are Non Covered and not payable.

Denial Risk

Non-reimbursed (EIU) codes

Codes designated 'EIU: Procedure/service not reimbursed by the Plan: Not subject to pre-service review' indicate services the Plan will not reimburse and thus submitting without checking EIU/CPCP may lead to denial or non-payment.

Examples include intrafacet implant codes (0221T, 0222T) and other EIU-designated procedures.

Prior Authorization

MP Criteria review-required codes

Codes designated 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' should be submitted for Recommended Clinical Review to avoid post-service review; failure to submit may result in post-service review and potential denial.

0253T and other MP Criteria entries require pre-service Recommended Clinical Review when applicable.

Prior Authorization

Submit MP Criteria codes for clinical review

Provide clinical documentation aligning with the referenced Medical Policy when submitting pre-service.

Denial Risk

EIU-coded services are not reimbursed

Services labeled 'EIU: Procedure/service not reimbursed by the Plan' are not reimbursed and are not subject to pre-service review; claims for these codes risk denial as not reimbursed.

Examples: 0449T, 0464T, 0524T entries flagged as EIU should be checked against CPCP before billing.

Denial Risk

Non‑reimbursed (EIU) codes

Codes 0602T and 0603T are designated EIU: procedure/service not reimbursed by the Plan; not subject to pre-service review (check EIU policy).

Billing these EIU-designated monitoring/GFR codes will likely result in nonpayment.

Prior Authorization

MP Criteria — submit for recommended clinical review

These codes are labeled MP Criteria: procedure/service reviewed against Medical Policy Criteria. Submit for recommended clinical review to avoid post-service review—failure to submit may trigger post-service claim review or denial.

Examples: 0614T, 0632T, 0643T, 0645T, 0659T — include full clinical rationale when submitting.

Prior Authorization

Submit for Recommended Clinical Review

Codes grouped as 'MP Criteria' require submission for Recommended Clinical Review to avoid post-service review; failure to submit may trigger post-service review or denial.

0784T–0789T and other neurostimulator Category III codes require pre-service review when indicated.

Note

PROVIDER ACTIONS (general MP Criteria submission guidance)

Items labeled 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review; failure to obtain the recommended pre-service/review may trigger post-service denial or payment review.

Examples include 0872T–0875T and many A20xx/A203x entries — follow MP submission guidance.

DocumentationProviders should include detailed procedure description and justification when submitting unlisted codes for review.

EIU

DefinitionProcedure/service not reimbursed by the Plan; classified as EIU in the code group listings.

Claim riskBilling EIU-coded services will likely result in denial/nonpayment because they are not reimbursed by the Plan.

Policy referenceProviders should consult the EIU section of the Clinical Payment and Coding Policy (CPCP) for details and exceptions.

MP Criteria

DefinitionProcedure/service reviewed against Medical Policy Criteria; submission for Recommended Clinical Review (predetermination) is advised to avoid post-service review.

Provider actionSubmit supporting clinical documentation for Recommended Clinical Review when codes are labeled 'MP Criteria'.

Denial riskFailure to obtain recommended pre-service review may trigger post-service medical necessity review and potential denial.

Non Covered

DefinitionProcedure/service not covered by the Plan; explicitly labeled 'Non Covered' in the code list.

Pre-service reviewNon Covered services are not subject to pre-service review and will be denied if billed to the Plan.

ExamplesExamples in the list include codes such as 0811T and 0812T (remote multi-day complex uroflowmetry) designated Non Covered.

MP Criteria (duplicate definition entry)

DefinitionProcedure/service reviewed against Medical Policy Criteria; submission for Recommended Clinical Review is advised to avoid post-service review.

Action requiredWhen a code is labeled 'MP Criteria', providers should submit clinical documentation and request Recommended Clinical Review (predetermination).

ExamplesCodes across the list (e.g., neurostimulation, leadless pacemaker procedures, select T-codes) are shown as MP Criteria.

EIU (duplicate definition entry)

DefinitionProcedures/services for which the Medical Policy Coverage statement indicates they are experimental, investigational, and/or unproven in all situations (EIU).

Reimbursement and reviewEIU-classified services are described as not reimbursed by the Plan and are not subject to pre-service review per the document guidance.

Check CPCPProviders should check the EIU section of the Clinical Payment and Coding Policy (CPCP) for additional details and any exceptions.

Non Covered (duplicate definition entry)

DefinitionProcedure/service not covered by the Plan; not subject to pre-service review.

Billing consequenceClaims for Non Covered services will be denied; providers should not expect reimbursement for codes labeled 'Non Covered'.

ExamplesTransportation ancillary codes and certain supply codes are listed as Non Covered in the extract (e.g., A0888).

Unlisted (definition)

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

Prior authorizationUnlisted codes may require prior authorization depending on contract terms; submit full procedure description when requesting review.

Documentation expectationInclude detailed description (type, time, supplies/materials) because unlisted codes lack specific code descriptors.