Recommended Clinical Review, Post-Service Review and Non-Covered Procedure Code List (Plastic/Reconstructive Surgery subset)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Texas policy alerts
Know when Blue Cross Blue Shield - Texas releases new policies or updates existing guidance.
Monitor payer policy activity
This document lists procedure codes used by Blue Cross Blue Shield - Texas that are subject to medical policy review categories (MP Criteria), recommended clinical (predetermination) review, post-service review, unlisted classifications that may require prior authorization, or codes designated as not covered/experimental; it affects providers submitting claims for the listed procedures.
No material clinical or coverage changes in this revision.
Coverage & Review Classifications
MP Criteria — Recommended Clinical Review
Covered when submitted for Recommended Clinical Review and meet applicable medical policy criteria.
Submit for Recommended Clinical Review (Predetermination) to avoid post-service review
Recommended Clinical Review requirement
Covered when submitted for Recommended Clinical Review as indicated.
Applies to codes marked MP Criteria in the list
Coverage pathways by code designation
Coverage/Review pathways based on code group designation.
Applies to many listed CPT codes (e.g., 31647, 32994, 33285, 33289, 33361, 36465, 36475, 36478, 36482).
Applies to codes such as those explicitly labeled EIU in the list (see coding entries).
Applies to codes like 31299, 31599, 31899, 32999, 33999, 36299.
MP Criteria: Recommended Clinical Review
Covered when submitted and reviewed per Medical Policy Criteria; specific grouping indicates required handling.
Appears for many CPT codes in chunks 72-91 (endovenous ablation, vein therapy, transcatheter vascular procedures).
Excluded/Not Reimbursed (EIU)
Not covered when labeled EIU.
Examples include codes explicitly marked EIU in the list (e.g., 36836, 36837, select laboratory and device codes).
MP Criteria — Recommended Clinical Review
Covered when reviewed and meet Medical Policy Criteria (submit for Recommended Clinical Review):
Examples in this segment include head/oral procedures and multiple gastric/bariatric procedure codes (see coding groups).
Processing categories
Coverage/processing stance shown per code group.
Examples: hepatic/liver ablation codes (47370, 47382, 47383), urologic and continence device codes, and others listed in coding groups.
Examples provided in the code groups (e.g., 47379, 47399, 47579).
Examples: select laboratory and device codes cited in chunks 116-117 (e.g., 53451-53454).
Coverage by utilization classification
Coverage stance depends on the code classification:
Examples across the document include numerous procedure groups (e.g., neurostimulation, breast, bariatric, genital procedures).
Examples: many unlisted CPT entries (e.g., 54699, 55559, 59898).
Examples: intracranial angioplasty/stent and other explicitly EIU-listed procedures (e.g., 61630, 0274T/0275T).
Recommended Clinical Review (MP Criteria)
Covered when reviewed under Medical Policy Criteria and submitted for Recommended Clinical Review to avoid post-service review.
Applies to multiple listed CPT codes including neurostimulator and related procedures (see coding groups).
Excluded / EIU
Not reimbursed by the Plan and not subject to pre-service review; check EIU policy.
Example: CPT 64628 and 64629 are designated EIU in this segment.
Unlisted / Prior Authorization
Unlisted procedures are not specifically defined and may be subject to contract or clinical review; prior authorization may be required per contract.
See individual unlisted CPT entries in the coding groups for examples and potential PA notes.
Coverage classification: EIU vs MP Criteria vs Unlisted
Coverage classification in this excerpt is determined per-code as follows:
Examples include 0062U, 0063U, 0232T (PRP), and other EIU laboratory/technology codes listed.
Examples include 0071T, 0072T, 0076T, and numerous procedural CPTs designated MP Criteria in the list.
Example: many unlisted CPTs across the document; check per-code entries for PA notes.
Per-code utilization designations
Coverage and review stance is defined per-code as either EIU (not reimbursed) or MP Criteria (requires Recommended Clinical Review).
Examples include 0274T, 0275T, 0278T, 0335T, 0347T, 0348T, and multiple other T/U codes flagged EIU.
Examples include 0308T, 0312U (MP periods), 0331T, 0332T, 0352T, 0354T, 0402T, 0408T-0418T, 0422T, etc.
Non Covered procedure codes are services that the Plan does not cover. These entries indicate the procedure/service is not covered by the Plan and, per the file instructions, are not subject to pre-service review. Providers should not expect reimbursement for services listed as Non Covered and should consult contract terms for member-specific coverage details.
Procedures classified as Experimental, Investigational, Unproven (EIU) are identified in the code list as services that the medical policy deems unproven in all situations; the Plan designates these codes as not reimbursed. EIU entries are explicitly labeled in the code group field and are not subject to pre-service review; providers should check the Clinical Payment and Coding Policy (CPCP) for additional guidance where referenced.
Examples of codes described in the list with the label 'EIU: Procedure/service not reimbursed by the Plan' include musculoskeletal and nasal procedures (for example, 22527, 22586, 30468, 30469 and related entries). These examples show the Plan’s explicit exclusion from reimbursement and the instruction to consult the CPCP for EIU policy details.
Code entries with the Code Group noted as EIU are treated as excluded from reimbursement by the Plan; the list uses this Code Group & Description field to indicate that these services are not reimbursed and not subject to pre-service review (see specific EIU code entries for dates and details).
The codes 36836 and 36837 are explicitly designated EIU in the code list with the description: Procedure/service not reimbursed by the Plan. The entries include effective and ending dates for the classification period.
The document contains many individual code examples designated as EIU; sample entries include 0274T, 0275T and 0335T, each annotated in the code group as Procedure/service not reimbursed by the Plan and therefore excluded from reimbursement.
The code list repeatedly emphasizes that procedures labeled EIU are not reimbursed by the Plan and are not processed through pre-service review. Several sections list EIU-designated codes (for example in head/neck, gastrointestinal, and vascular groups) and direct providers to the CPCP for EIU policy details.
Throughout the list, procedures classified as EIU are presented as exclusions from reimbursement. The file’s usage of the EIU label consistently indicates the service is not reimbursed by the Plan and therefore would not be approved or paid when billed to the Plan.
CPT codes 64628 and 64629 are noted in the file as EIU with the Code Group & Description indicating Procedure/service not reimbursed by the Plan. The listing states these entries are not subject to pre‑service review and points providers to the CPCP for EIU policy.
When a code in the list is marked with the EIU label, the document describes that entry as Procedure/service not reimbursed by the Plan. This classification signals explicit exclusion from reimbursement; providers should not submit these services expecting payment and may consult the CPCP for further explanation.
Codes labeled 'EIU' appear in multiple clinical sections (e.g., spine, bronchoscopy, laboratory assays). The list’s EIU designation is consistently accompanied by the statement that the procedure is not reimbursed by the Plan and is not subject to pre‑service review; the CPCP is referenced for policy details.
The code list includes many EIU examples; entries such as 0274T, 0275T, and multiple neurostimulator-related T-codes (e.g., 0429T–0433T) are explicitly marked EIU: Procedure/service not reimbursed by the Plan, underscoring that those services are excluded from reimbursement.
Services coded as EIU are excluded from reimbursement by the Plan. The list includes laboratory and advanced technology codes (for example, 0062U, 0063U, and 0232T) flagged as EIU, and the document reiterates that EIU services are not subject to pre-service review and are not reimbursed.
Entries labeled EIU are described in the file as procedures/services that the medical policy considers experimental, investigational, or unproven. The Plan’s stance is that these procedures are not reimbursed in all situations and providers should check the CPCP for any additional guidance.
Where a procedure is labeled EIU, the code line in the file explicitly states that the procedure/service is not reimbursed by the Plan. This is a definitive exclusion—billing these codes will result in non-payment per the document’s instructions.
The file’s definition of EIU is that the service is experimental, investigational, or unproven and therefore considered unproven in all situations; such entries are treated as not medically necessary for reimbursement purposes and are excluded from coverage.
Unlisted procedure codes are identified separately in the file as services not specifically defined or classified. These entries may be subject to contract or clinical review, and the document notes that Prior Authorization may be required per contract agreement; providers should confirm PA requirements before scheduling or billing unlisted services.
Procedure Codes and Groupings
| 47999 | Unlisted procedure, biliary tract. |
| 48999 | Unlisted procedure, pancreas. |
| 49329 | Unlisted laparoscopy procedure, abdomen, peritoneum and omentum. |
| 49659 | Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy. |
| 49999 | Unlisted procedure, abdomen, peritoneum and omentum. |
| 50250 | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed. |
| 50360 | Renal allotransplantation, implantation of graft; without recipient nephrectomy. |
| 50541 | Laparoscopy, surgical; ablation of renal cysts. |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed. |
| 50549 | Unlisted laparoscopy procedure, renal. |
| 15011 | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less. |
| 15012 | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof. |
| 15013 | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin. |
| 15014 | Preparation of skin cell suspension autograft; each additional 25 sq cm of harvested skin or part thereof. |
| 15015 | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less. |
| 15016 | Application of skin cell suspension autograft; each additional 480 sq cm or part thereof. |
| 15017 | Application of skin cell suspension autograft to high risk sites (face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, multiple digits); first 480 sq cm or less. |
| 15018 | Application of skin cell suspension autograft to high risk sites; each additional 480 sq cm or part thereof. |
| 15271 | Application of skin substitute graft 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 graft to trunk, arms, legs; 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 or 1% body area infants/children. |
| 15274 | Application of skin substitute graft to trunk, arms, legs; each additional 100 sq cm wound surface area or part thereof. |
| 15275 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, multiple digits; total wound surface area up to 100 sq cm; first 25 sq cm or less. |
| 15276 | Application of skin substitute graft to face and high risk sites; each additional 25 sq cm wound surface area. |
| 15277 | Application of skin substitute graft to face and high risk sites, total wound surface area >=100 sq cm; first 100 sq cm or 1% body area infants/children. |
| 15278 | Application of skin substitute graft to face and high risk sites; each additional 100 sq cm or part thereof. |
| 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. |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts. |
| 15776 | Punch graft for hair transplant; more than 15 punch grafts. |
| 15780 | Dermabrasion; total face. |
| 15781 | Dermabrasion; segmental, face. |
| 15782 | Dermabrasion; regional, other than face. |
| 15783 | Dermabrasion; superficial, any site (eg, tattoo removal). |
| 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 | Rhytidectomy; neck with platysmal tightening (platysmal flap). |
| 15828 | Rhytidectomy; cheek, chin, and neck. |
| 15829 | Rhytidectomy; SMAS flap. |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. |
| 15832 | Excision, excessive skin and subcutaneous tissue; thigh. |
| 15833 | Excision, excessive skin and subcutaneous tissue; leg. |
| 15999 | Unlisted procedure, excision pressure ulcer (Unlisted: may be subject to contract/clinical review; PA may be required). |
| 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. |
| 17340 | Cryotherapy (CO2 slush, liquid N2) for acne (EIU: not reimbursed). |
| 17360 | Chemical exfoliation for acne (eg, acne paste, acid). |
| 17380 | Electrolysis epilation, each 30 minutes. |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue. |
Predetermination, Prior Authorization, and Documentation
Prior Authorization may be required for Unlisted codes
Prior authorization may be required for unlisted procedure codes. Unlisted/undefined procedure codes (eg, CPT codes in the 19x99, 21x99, 22x99, 23x99, 31x99, 33x99, 34x99, 36x99, 37x99, 38x99, 41x99, 42x99, 43x99, 47x99, 49x99, 52x99, 59x99, 60x99, 77x99, 78x99, 83x99, 88x99, 90x99, 91x99, 93x99, 94x99, 95x99 series and similar) are not specifically defined or classified and may be subject to contract and clinical review. To avoid post-service denials or claim adjustments, submit a predetermination/prior authorization when using unlisted codes per the member contract.
- Unlisted codes frequently carry a note: "Prior Authorization may be required per contract agreement."
- Searchable code list highlights many unlisted codes across specialties — check the code description group before billing.
- When billing an unlisted code, providers should submit a detailed operative report, description of the procedure, and any supporting clinical documentation to allow review.
- If an unlisted code maps to a Medical Policy (MP Criteria) code group, submit for Recommended Clinical Review (predetermination) to avoid post-service review.
Recommended Clinical Review for MP Criteria codes
Procedures mapped to Medical Policy Criteria (MP Criteria) should be submitted for Recommended Clinical Review (predetermination) prior to service. Submitting clinical documentation and a predetermination helps avoid post-service denials and supports medical necessity evaluation.
- "MP Criteria" indicates the procedure/service is reviewed against a Medical Policy — highlighted codes may require Recommended Clinical Review.
- Providers should submit clinical notes, imaging, prior conservative therapy documentation, and operative details as applicable.
- Submit documentation for cortical mapping, magnetoencephalography (MEG), intracranial recordings, neurostimulation programming, and other MP Criteria services to demonstrate indications and medical necessity.
EIU — verify reimbursement policy
Certain codes are designated EIU (Experimental, Investigational, Unproven) and are not reimbursed by the Plan. EIU-coded services are not subject to pre-service review but may be denied. Providers must check the Clinical Payment and Coding Policy (CPCP) for details and verify reimbursement policy before rendering services.
- EIU = Experimental, Investigational, Unproven — not reimbursed in all situations.
- Examples of EIU denials include (not exhaustive): 20560/20561 (needle insertions without injection), 22526/22527 (percutaneous intradiscal electrothermal annuloplasty historically EIU), 0232T (platelet rich plasma injections), 0335T (sinus tarsi implant), and many advanced technology or novel lab tests (multiple U-codes).
- Check the payer's CPCP / searchable code list for EIU and advanced technology codes before scheduling procedures.
- EIU-coded services are typically listed as: "Procedure/service not reimbursed by the Plan. Not subject to pre-service review. Check EIU policy (CPCP)."
Prior authorization may be required for unlisted procedure codes
When submitting unlisted procedure codes, include a prior authorization request when contract language indicates it may be required and provide complete documentation describing the service components, rationale, and any comparable CPT codes performed.
- Unlisted code billing tips: include operative report, procedure description, estimated time, imaging, and intraoperative findings.
- Provide comparison to analogous CPT code(s) and explain why an unlisted code is necessary.
- Providers should submit procedures designated as unlisted to the predetermination/prior authorization process when noted in the searchable code list.
Searchable code list / highlighted codes may require prior authorization
Use the searchable code list / CPCP to identify EIU and advanced technology codes, highlighted MP Criteria codes, and codes that may require prior authorization. This list is the authoritative source for code status and effective/ending dates.
- The file is searchable (CTRL+F) — enter the procedure code or description to check status.
- Highlighted codes in the searchable list indicate those that may require prior authorization or Recommended Clinical Review.
- Check effective and ending dates on the code list before submission.
Providers should submit procedures designated for review with supporting documentation
Providers should submit all procedures designated MP Criteria or Unlisted with supporting clinical documentation to the payer's predetermination/prior authorization process. For MP Criteria codes, include documentation that addresses the specific Medical Policy criteria.
- For MP Criteria codes: submit clinical notes, imaging, prior treatments, and objective findings tied to the policy criteria.
- For unlisted codes: submit operative reports, detailed procedure descriptions, comparable CPT crosswalks, and medical necessity justification.
- For cortical mapping (CPT 95961/95962) and related neurophysiology services, include EEG/MEG reports, indication for mapping, and perioperative notes.
Recommended Clinical Review / documentation
Documentation must support medical necessity for MP Criteria services. Submit relevant clinical records, imaging, prior conservative care, procedure reports, and physician rationale. For services involving cortical mapping, intraoperative stimulation, MEG, or depth electrode recordings, include detailed neurodiagnostic reports and operative notes.
- Recommended Clinical Review / documentation: clinical history, prior therapies, diagnostic test results, imaging, consultation notes, and plan of care.
- Submit cortical mapping documentation: indication, mapping methodology, results, and how findings affected surgical planning.
- For MEG and intracranial recordings, include the full neurophysiology report and interpretation.
Unlisted codes and prior auth risk
Unlisted code usage carries prior authorization and documentation risk. Always include a clear description of the procedure rationale, operative details, and comparison to standard CPT codes. Failure to adequately document may result in post-service denial or reimbursement denial for EIU-coded services.
- Unlisted code documentation/prior auth: operative report, time, equipment, implants, and all relevant clinical justifications.
- If an unlisted procedure maps to an EIU policy, anticipate non-reimbursement; verify in CPCP before performing the service.
- Unlisted codes that also fall under MP Criteria should be submitted for Recommended Clinical Review to avoid post-service review.
Examples of EIU denials
Examples of EIU denials are provided in the searchable list. Common categories include novel laboratory tests (U-codes), many T-codes and newer technology codes (eg, platelet-rich plasma, certain focused ultrasound and implantable device codes), and specific CPTs expressly listed as EIU. Verify each code in the CPCP before ordering or performing the service.
Check CPCP for EIU and advanced tech codes
Check the Clinical Payment and Coding Policy (CPCP) for details on EIU, advanced technology, and other non-reimbursable codes. The CPCP is the reference to confirm reimbursement status and to determine whether a prior authorization or predetermination is required.
- Operational note: use CPCP to reconcile code status (MP Criteria vs EIU vs Unlisted) before scheduling the procedure.
- If CPCP lists a code as EIU/not reimbursed, obtain patient acknowledgement and consider alternate covered therapies.
Document Purpose and Scope
This code-level operational list is intended to guide providers and billing staff on how individual CPT/HCPCS procedure codes are processed by the Plan: identifying codes that require submission for Recommended Clinical Review (MP Criteria), codes that may be Unlisted and require confirmation of prior authorization per contract, and codes that are designated EIU (not reimbursed) or Non Covered.
Terms and Abbreviations
Document Revision History
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.