CurrentPremera BluecrossPolicy N/A

Non-covered Services and Procedures (Benefit Coverage Guideline)

Lists categories of services, specific procedure and billing codes, and other items the Premera plan does not cover; intended for providers and applies when billing for services under the plan.

Policy Summary

PayerPremera Bluecross

PolicyNon-covered Services and Procedures (Benefit Coverage Guideline)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements before ordering or billing for listed non-covered services and codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+Example codes listed

MultipleNon-covered categories

Includes noncovered codesExplicit noncovered codes

Includes 2025New MR safety codes 2025

2014-2025Policy history range

Non-covered Service Categories and Rules

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Non-covered Service Categories

Non-covered services include but are not limited to the following categories

Non-covered categories: Cosmetic services that do not restore physical function; Custodial care (care that does not require regular services of trained medical or allied health professionals); Nonmedical services (spiritual/bereavement, legal or financial counseling, living expenses, nonemergency transportation, meals); Nonprescription (over-the-counter) drugs, supplements, or supplies; Personal care/convenience items that do not provide a medical benefit; Nonmedical equipment (DME/HME) that is not therapeutic or useful in the absence of illness or injury

Exceptions: cosmetic services that meet reconstructive medical necessity criteria may be allowed per related policies

Exceptions for otherwise non-covered cosmetic procedures are recognized when the service meets reconstructive medical necessity criteria. Specifically, cosmetic services that "alter the appearance or shape of a body part" are generally not covered, but reconstructive procedures that restore or improve physical function may be allowed if the medical necessity criteria are met and documented. Coverage remains subject to the member contract effective date and the date the service was provided.

The policy identifies certain items and HCPCS/S-codes as explicitly noncovered or not medically necessary. Examples called out in the coding lists include A0888 (noncovered ambulance mileage) and service-level entries such as S9976 (lodging, per diem), S9977 (meals, per diem), and S9986 (not medically necessary service). Providers should assume claims for these listed items may be denied unless other coverage rules or prior authorization apply.

Non-covered services listed in this policy may also be defined by the member's contract; when there is a difference between the table and the member contract, the member contract prevails. The policy notes that services, supplies, drugs, or medications related to an excluded condition or those exceeding allowable charges or maximum benefits may be non-covered per the member's contract.

The policy explicitly states that nonprescription (over-the-counter) drugs, supplements, or supplies that can be purchased without a prescription are not covered. These items are identified as products that do not require a prescription and therefore fall under the plan's non-covered exclusions.

Codes that are flagged in the document as Not medically necessary or Noncovered should be treated as not medically necessary for coverage and may result in claim denials. The policy lists examples such as S9986 to illustrate this guidance.

Therapeutic Drug Monitoring Panels (CPT 0517U–0519U)

Therapeutic drug monitoring panels listed in the coding section are included among services identified as not covered

Therapeutic drug monitoring panels (not covered): CPT 0517U: Therapeutic drug monitoring; 80 or more psychoactive drugs or substances, LC-MS/MS, plasma, qualitative and quantitative; CPT 0518U: Therapeutic drug monitoring; 90 or more pain and mental health drugs or substances, LC-MS/MS, plasma, qualitative and quantitative; CPT 0519U: Therapeutic drug monitoring; medications specific to pain, depression, and anxiety, LC-MS/MS (listed among non-covered services)Panel sizes as specified in CPT descriptors (e.g., 80+, 90+)

Providers should confirm medical necessity and member contract benefits prior to ordering or billing for these panels

Procedure and Supply Codes

Denial Risk

Provider action: Codes listed in non-covered services

Codes listed in non-covered services may result in claim denial if submitted without prior authorization or when member contract excludes the service. Providers must verify member coverage and authorization requirements for each code and service date. Contract exclusions (for example, items explicitly listed as noncovered or labeled “Not medically necessary”) may trigger denial even when clinical documentation is provided.

Verify member contract and benefit coverage before billing.
Obtain and document prior authorization when required by the payer.
Do not assume that presence of a CPT/HCPCS code in this list implies coverage.

Billing Rule

Provider action: Noncovered / Not Medically Necessary Items

Items and services explicitly listed as Noncovered / Not Medically Necessary should not be billed to the payer as covered services. When these codes are furnished, indicate on the claim when services were patient-paid or educational/noncovered, and include supporting documentation when applicable.

Do not bill noncovered items to Premera Bluecross for coverage.
If provided as a courtesy or self-pay, document patient acknowledgement and payment.
Examples include codes marked Not medically necessary (e.g., S9986) and other noncovered procedure codes.

Denial Risk

Provider action: Contract exclusions may trigger denial

Contractual exclusions (including those in member certificates, benefit handbooks, or state-mandated exclusions) may lead to claim denial even if clinical documentation supports medical necessity. Providers should review the member’s specific plan terms and any applicable state or federal mandates prior to providing services.

Check for plan-specific exclusions and medical necessity limitations.
When in doubt, contact Premera Bluecross provider services or utilize payer portals to confirm benefits.
Document conversations and authorizations in the medical record to support appeals if needed.

Documentation Required

Provider action: Coding and claim documentation

Accurate coding and thorough documentation are required to support medical necessity, claims processing, and potential appeals. Claims must include appropriate CPT/HCPCS codes, modifiers, diagnosis linkage, and sufficient clinical documentation (e.g., progress notes, test results, prior authorization forms).

Link each procedure code to an appropriate ICD-10 diagnosis that supports medical necessity.
Use modifiers where clinically appropriate and supported by payer guidance.
Include prior authorization number and supporting documentation on claim when authorization was obtained.

Documentation Required

Provider action: Billing and documentation considerations

Billing and documentation considerations: maintain contemporaneous medical records that justify services billed, retain copies of prior authorizations, and follow payer-specific claim submission rules (electronic/837 formats, UB-04 or CMS-1500). For items listed as noncovered, clearly indicate patient responsibility when applicable and avoid submitting these as covered charges.

Submit claims using the correct claim form and electronic format as required by Premera Bluecross.
Keep records of patient notifications when services are noncovered or deemed not medically necessary.
When billing DME or supplies, include supplier documentation, certificates of medical necessity, and correct HCPCS codes.

Billing, Authorization, and Documentation Guidance

Prior Authorization

Prior authorization may be required for select DME

Certain durable medical equipment items shown in the code lists (for example, breast pumps and patient lifts) may require prior authorization per DME policy or payer requirements; confirm authorization rules before providing or billing.

Examples: E0602 (breast pump), E0635/E0636 (patient lift/multipositional support).
Follow separate DME prior authorization procedures when applicable.

Prior Authorization

Confirm member benefit limits and authorization requirements

Coverage for services is subject to the limits and conditions of the member's benefit plan; providers must confirm member-specific benefit limits and whether prior authorization is required under the member contract and effective dates.

If the member's contract differs from this policy, the member contract prevails.
Verify the member contract effective date and the date of service to determine coverage.

Note

Confirm medical necessity and contract effective date prior to ordering

Verify medical necessity and member contract effective date before ordering or billing services that fall into the policy’s non-covered categories, as coverage depends on both medical necessity and the member's contract.

The plan covers services that are medically necessary to prevent, evaluate, diagnose, or treat an illness, injury, or disease.
If coding or service falls under non-covered categories the claim may be denied.

Documentation Required

Verify coverage via member booklet or member services

Check member booklet or contact member services to determine whether a specific service or supply is covered or excluded under the member's contract before providing service or submitting a claim.

The member booklet lists complete non-covered services for a member's contract.
When differences exist, the member contract prevails over this policy.

Denial Risk

Denial risk for services in non-covered categories

For services in non-covered categories, be aware that claims may be denied; review the policy's examples of non-covered items and confirm coverage prior to providing services to avoid denials.

Non-covered categories include cosmetic services that do not restore function, custodial care, nonprescription drugs, and nonmedical services.
Examples of noncovered/not medically necessary service codes include S9976, S9977, and S9986 which may trigger denials.

Billing Rule

Use appropriate codes and confirm contract/service dates on claims

Billing must use the appropriate CPT/HCPCS codes and descriptors shown in the policy; coverage decisions also depend on the member contract effective date and the date the service was provided.

Use the policy's code descriptors when submitting claims for DME, transportation, and supply items.
Confirm the member contract effective date and date of service — the member contract controls coverage.

Billing Rule

Report correct HCPCS codes and descriptors for DME and supplies

When billing DME, supplies, or transportation items, submit the correct HCPCS codes and official descriptors on claims to support coverage determination.

Examples include HCPCS codes for transportation (A0110–A0210), compression stockings (A6530 series), and monitors/supplies (A4660, A4931).
Include all required code descriptors and supporting documentation on the claim.

Documentation Required

Verify member benefits and contract details

Consult the member booklet or contact member services to confirm specific benefit limitations, exclusions, and whether services are covered under the member's contract before ordering or billing.

The non-covered services defined in a member's contract may include items furnished in connection with a non-covered condition or services with exhausted benefits.
If there is a difference between this policy and the member contract, the member contract prevails.

Denial Risk

Denial risk when service falls into non-covered categories

Services or supplies that fall into the policy's listed non-covered categories (for example cosmetic services that do not restore function, custodial care, and nonprescription items) may be denied if billed.

Direct or indirect complications and aftereffects from non-covered cosmetic services are not covered.
Custodial care primarily assisting with activities of daily living is not covered and may be denied.

Denial Risk

Noncovered / not medically necessary codes may trigger denials

Some codes are explicitly identified as noncovered or not medically necessary in the policy; billing these codes (e.g., S9976, S9977, S9986) may result in claim denial.

S9976 — Lodging, per diem, not otherwise classified.
S9977 — Meals, per diem, not otherwise specified.
S9986 — Not medically necessary service (patient is aware the service is not medically necessary).

Denial Risk

Contract exclusions can cause denials; confirm contract exclusions

Services, supplies, drugs, or medications furnished in connection with or directly related to conditions or services that are excluded under the member's contract may be non-covered and denied per the contract.

Examples of contract exclusions include amounts exceeding allowable charges, experimental/investigational services (with limited clinical trial exception), and services covered by other sources of payment.
Confirm exclusions in the member booklet prior to service delivery.

Key Terms and Code System Definitions

Cosmetic — definition

DefinitionA cosmetic service is one that alters the appearance or shape of a body part and does not relieve, improve, correct, or restore physical function.

Coverage ruleCosmetic services are not covered unless they meet reconstructive medical necessity criteria per related policies.

ExclusionsDirect or indirect complications and aftereffects from non-covered cosmetic services are not covered (e.g., pain resulting from the procedure).

Custodial care — definition

DefinitionCustodial care is care that does not require the regular services of trained medical or allied health professionals and primarily assists with activities of daily living (eg, getting in and out of bed, bathing, dressing, help with walking).

Coverage ruleCustodial care is not covered under the plan when it does not require skilled medical services.

ExamplesAssistance with ADLs such as bathing, dressing, ambulation are typical custodial activities referenced in the policy.

Noncovered ambulance mileage (A0888)

Noncovered exampleA0888 — Noncovered ambulance mileage: per mile for miles traveled beyond the closest appropriate facility.

ContextListed among transportation and ancillary HCPCS as explicitly noncovered mileage beyond the closest appropriate facility.

Provider actionVerify member contract and applicable transportation coverage prior to billing for ambulance mileage beyond the closest appropriate facility.

CPT — definition

PurposeCPT (Current Procedural Terminology) codes identify medical, surgical, and diagnostic services and are maintained by the American Medical Association.

UseCPT codes are commonly used for procedures and procedural billing/documentation.

MaintenanceCodes are developed and maintained by the American Medical Association.

HCPCS — definition

PurposeHCPCS (Healthcare Common Procedure Coding System) Level II codes identify supplies, equipment, devices, and services not in the CPT system and are maintained by CMS.

UseHCPCS Level II codes are commonly used for goods and services such as DME, supplies, and transportation.

MaintenanceHCPCS codes are developed and maintained by the Centers for Medicare and Medicaid Services.

ICD-10 — definition

DefinitionICD-10 is the International Classification of Diseases maintained by the World Health Organization; it is a classification system for diseases, signs, symptoms, and findings used for diagnoses.

UseICD-10 codes are commonly used to report diagnoses on claims and medical records.

AuthorityMaintained by the World Health Organization.

Revenue code — definition

PurposeRevenue codes identify the inpatient department in which the service was given, the types of services provided, and the supplies used.

UseRevenue codes are used for inpatient billing to indicate department and service type (examples in the policy include 0902–3109 series excerpt).

ScopeRevenue codes assist in categorizing facility charges and aligning services with billing departments.

Policy Revision History

2014-10-13created

New Benefit Coverage Guideline added to Administrative section.

2015-07-14annual_review

Annual review with Benefit Exclusion table updates (added G9012, S5109; removed infertility-related codes) and additions to counseling/education exclusions.

2016-04-14coding_update

Coding update removing HCPCS L1830 and L1833 prefabricated codes.

2016-08-22coding_update

Added CPT codes 0366T and 0367T under Benefit Exclusion category.

2017-02-01annual_review

Annual review approved January 10, 2017 with additional codes added.

2022-03-01annual_review

Annual review approved February 7, 2022; guideline statements unchanged.

2022-04-01coding_update

Added new HCPCS codes H2038, T2050, and T2051.

2022-10-01coding_update

Added HCPCS codes T1032 and T1033.

2022-11-01coding_update

Coding update: removed healthcare categories within the coding table and listed all codes by code set; added ABA note to HCPC codes H5108-H5111.

2023-08-01annual_review

Annual review approved July 24, 2023; guideline statements unchanged.

2023-09-01coding_update

Corrected multiple incorrect code descriptions.

2023-10-01coding_update

Added new HCPCS codes A9268, A9269, H2040, H2041 and V2526.

2024-01-01coding_update

Added CPT codes 0753T and 0756T and new CPT codes 0827T; added CPT codes 92065 and 92066 as contract exclusions; added HCPCS Q0519 and Q0520 and related codes Q0516-Q0518 effective 10/1/2024.

2024-03-01coding_update

Removed HCPCS codes A4267-A4269 due to federal mandate and A4287 due to change in benefit guidelines.

2024-07-01coding_update

Removed CPT code 96161 due to it being added to the Preventive policy.

2024-10-01annual_review_coding_update

Annual review approved September 9, 2024; added new CPT codes 0517U, 0518U, 0519U, 0520U and HCPCS codes Q0516-Q0520; policy statements unchanged.

2024-12-01coding_update

Added HCPCS codes Q0224, M0224, Q0249, M0249, and M0250 for Noncovered Emergency Use Authorization drugs.

2025-01-01coding_update

Added new CPT codes 76014-76019 and removed HCPCS codes Q0516-Q0520.

2025-07-01coding_update

Added HCPCS codes E0201, E1022, and E1023 (late add for April 1, 2025 coding update) and added HCPCS A6610 to match criteria.

2025-09-01annual_review

Annual review approved August 25, 2025; policy statements unchanged.

2025-10-01coding_updateLatest

Added new HCPCS code E0150 to match criteria.

OpenPayer

Non-covered Services and Procedures (Benefit Coverage Guideline)

Non-covered Service Categories and Rules

Procedure and Supply Codes

Billing, Authorization, and Documentation Guidance

Provider Ordering and Verification

Explicit Non‑Covered Items

Key Terms and Code System Definitions

Policy Background

Policy Revision History