Non-reimbursable procedure code list
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This document lists procedure codes and descriptions that Blue Cross Blue Shield of Texas identifies as non-reimbursable for applicable member plan documents; it applies only to plans not subject to the Texas Insurance Code administered by BCBS Texas (effective 1, 2022) as specified.
No material clinical or coverage changes in this revision.
Non-reimbursable Procedure Code Listings
Non-reimbursable code listings
This document identifies procedure codes that are not reimbursable according to the member's plan documents and provides individual effective and end dates for codes where applicable. Applies only to plans not subject to the Texas Insurance Code administered by BCBS Texas (effective 1/1/2022).
Examples of listed non-reimbursable CPT/HCPCS codes
- 17340 — CRYOTHERAPY OF SKIN. Effective date: 12/01/2020. End date: 08/31/2025.
- 20560 — NDL INSJ W 0 NJX 1 OR 2 MUSC. Effective date: 12/01/2020. End date: (none listed).
- 20561 — NDL INSJ W 0 NJX 3 MUSC. Effective date: 12/01/2020. End date: (none listed).
- 20985 — CPTR-ASST DIR MS PX. Effective date: 09/01/2020. End date: (none listed).
- 22526 — IDET SINGLE LEVEL. Effective date: 01/01/2023. End date: (none listed).
- 22527 — IDET 1 OR MORE LEVELS. Effective date: 01/01/2023. End date: (none listed).
- 22586 — PRESCRL FUSE WI INSTR LS-S1. Effective date: 09/01/2020. End date: (none listed).
- 22836 — ANT THRC VRT BODY TETHRG <7. Effective date: 05/15/2024. End date: (none listed).
- 22837 — ANT THRC VRT BODY TETHRG 8+. Effective date: 05/15/2024. End date: (none listed).
- 22838 — REV RPLCIRMV THRC VRT TETHRG. Effective date: 05/15/2024. End date: (none listed).
- 22867 — INSJ STABLJ DEV WIDCMPRN. Effective date: 01/01/2023. End date: (none listed).
- 22868 — INSJ STABLJ DEV WIDCMPRN (continued in list).
Code table — informational
Informational code table: code entries provide code, description, effective date and end date when applicable. No explicit coverage criteria stated in this section.
Sample HCPCS/C and other codes
- C1827 — Effective date: 09/01/2023. End date: (none listed).
- C1832 — AUTO CELL PROCESS SYS. Effective date: 05/15/2024. End date: (none listed).
- C1841 — RETINAL PROSTH INT EXT COMP. Effective date: 12/01/2020. End date: 12/31/2022.
- C1842 — RETINAL PROSTH ADD ON. Effective date: 12/01/2020. End date: 12/31/2022.
- C9354 — ACELLULAR PERICARDIAL TISSUE MATRIX. Effective date: 12/01/2020. End date: (none listed).
- C9356 — TENOGLIDE TENDON PROT CM2. Effective date: 12/01/2020. End date: (none listed).
- C9358 — DERMAL SUBSTITUTE NATIVE NON DENA. Effective date: 12/01/2020. End date: (none listed).
- C9360 — DERMAL SUBSTITUTE NATIVE NON DENA. Effective date: 12/01/2020. End date: (none listed).
- E0855 — CERVICAL TRACTION EQUIPMENT. Effective date: 09/01/2020. End date: (none listed).
- E0856 — CERVIC COLLAR W AIR BLADDERS. Effective date: 09/01/2020. End date: (none listed).
- E0860 — TRACT EQUIP CERVICAL TRACT. Effective date: 09/01/2020. End date: (none listed).
- E0890 — TRACTION FRAME ATTACH PELVIC. Effective date: 09/01/2020. End date: (none listed).
- E0936 — CPM DEVICE OTHER THAN KNEE. Effective date: 12/01/2020. End date: (none listed).
- E0942 — CERVICAL HEAD HARNESS/HALTER. Effective date: 09/01/2020. End date: (none listed).
- E0944 — PELVIC BELT/HARNESS/BOOT. Effective date: 09/01/2020. End date: (none listed).
- E1632 — WEARABLE ARTIFICIAL KIDNEY. Effective date: 01/01/2023. End date: (none listed).
- E3000 — SPEECH VOLUME MODULATION SYS. Effective date: 05/15/2024. End date: (none listed).
- 60255 — CURRENT PERCEP THRESHOLD TST. Effective date: 09/01/2020. End date: (none listed).
- G0281 — ELEC STIM UNATTEND FOR PRESS. Effective date: 09/01/2020. End date: (none listed).
Code Lists and Examples
| 0432T | REPOS NSTIM APNEA STIMJ LD |
| 0433T | REPOS NSTIM APNEA SENSING LD |
| 0434T | INTERRO EVAL NPGS APNEA |
| C1827 | AUTO CELL PROCESS SYS |
| C1832 | AUTO CELL PROCESS SYS (C1832) |
| C1841 | RETINAL PROSTH INT EXT COMP |
| E0221 | INFRARED HEATING PAD SYSTEM |
| E0469 | LUNG EXPANS HIGH OSCIL NEB |
| G0428 | COLLAGEN MENISCUS IMPLANT PROCEDURE |
| J7604 | ACETYLCYSTEINE COMP UNIT |
| K1002 | CRANIAL ELECTROTHERAPY STIMULATION |
| L5991 | LOW PROS EXT OSSEO CONNECTOR |
| M0076 | PROLOTHERAPY |
| Q4321 | CAREGRAFT, per sq cm (effective 07/01/2024) |
| Q4322 | ALLOPLY, per sq cm (effective 07/01/2024) |
| Q4323 | AMNIOTX, per sq cm (effective 07/01/2024) |
| Q4324 | ACAPATCH, per sq cm (effective date not listed) |
| Q4325 | WOUNDPLUS, per sq cm (effective 07/01/2024) |
| Q4326 | DUOAMNION, per sq cm (effective 07/01/2024) |
| Q4327 | MOST, per sq cm (effective 07/01/2024) |
| Q4328 | SINGLAY, per sq cm (effective 07/01/2024) |
| Q4329 | TOTAL, per sq cm (effective 07/01/2024) |
| Q4330 | AXOLOTL GRAFT, per sq cm (effective 07/01/2024) |
Provider Impact and Billing Notes
Non-reimbursable services — applicability and billing note
Lists procedure codes identified as not reimbursable based on the member's plan documents; this list applies only to plans not subject to the Texas Insurance Code administered by Blue Cross and Blue Shield of Texas (effective 1/1/2022). Providers should not expect reimbursement for the services shown on this list when billing applicable member plans.
- Applies only to plans not subject to the Texas Insurance Code (effective 1/1/2022).
- Codes shown are services that are not reimbursable per the member's plan documents.
Temporary CPT (T) codes 0432T–0434T — descriptions and dates
Temporary CPT Category III codes 0432T–0434T are listed with their descriptions and effective/end dates; 0432T, 0433T and 0434T are effective 04/15/2022 with an end date of 12/31/2023.
- 0432T — REPOS NSTIM APNEA STIMJ LD; Effective date = 04/15/2022; End date = 12/31/2023.
- 0433T — REPOS NSTIM APNEA SENSING LD; Effective date = 04/15/2022; End date = 12/31/2023.
- 0434T — INTERRO EVAL NPGS APNEA; Effective date = 04/15/2022; End date = 12/31/2023.
HCPCS alpha and C-code entries — descriptions and effective dates
HCPCS alpha codes (A2001 and others) and certain C-codes are listed with descriptions and effective dates; these entries provide the code, short description and effective/end dates for billing reference.
Code list (informational) — no authorization rules in this section
This section lists HCPCS and CPT codes (mixed families) with their descriptions and effective/end dates for billing reference; no prior authorization or additional documentation requirements are stated here.
Q-code product listings — descriptions and dates (no PA specified)
Q-codes for grafts/allograft/amnion products are listed with descriptions and effective dates; this portion provides code-level billing descriptions but does not state prior authorization requirements.
Allograft/amniotic product Q-codes — per sq cm entries (07/01/2024 cluster)
Allograft/amniotic product Q-codes (for example CAREGRAFT, ALLOPLY, AMNIOTX) are billed per square centimeter and most entries in this group show an effective date of 07/01/2024.
Future-dated Q-code products and S-code listings — informational
Additional Q-code products and several future-dated entries (effective 05/15/2025, 06/15/2025, 09/15/2025) are listed along with a set of miscellaneous HCPCS S-codes; these are informational billing entries with their effective dates.
01/01/2026 CPT Category III (T) code additions — provider advisory
A long sequence of CPT Category III (T) and other T-codes are scheduled with an effective date of 01/01/2026; providers should note these codes and their effective date for future billing but the document does not specify authorization rules here.
Terminology and Code Format Notes
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