CurrentPremera BluecrossPolicy N/A
Non-covered Services and Procedures (Benefit Exclusions)
Premera Bluecross Benefit Coverage Guideline listing categories of services, supplies, and procedure codes that the plan does not cover (non-covered), with exceptions for reconstructive services when medical necessity criteria are met. The document provides descriptive coverage criteria and an extensive non-covered code list (CPT/HCPCS/G/CPT-like codes).
Policy Summary
PayerPremera Bluecross
PolicyNon-covered Services and Procedures (Benefit Exclusions)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateApr 1, 2026
Next Review Date
Key ActionIf there is a difference between the table information and the member's contract, the member's contract prevails; coverage depends on the member's contract effective date and the date the service was provided.
POLICY UPDATE CHANGES
No material clinical/coverage changes
ExtensiveNon-covered code list length
MultipleNon-covered categories
AllowedReconstructive exceptions
Coverage Summary
This guideline lists categories of services, supplies, and procedure codes that the plan does not cover. It explains that not all billable services with specific CPT/HCPCS/G-codes are covered — only services that are medically necessary and meet accepted standards of medicine are covered.