CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP028

Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

Defines procedure and supply codes that Blue Cross and Blue Shield of Illinois will deny as non-reimbursable because they are considered experimental, investigational, or unproven; applies to claims submitted to BCBS IL and providers billing covered members.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyNon-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

Policy CodePolicy CPCP028

Change TypeAdministrative (code list moved to attachment)

Effective DateMay 15, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation with claims; listed codes in the external code list will be denied as non-reimbursable without clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

May 15, 2025effective date

Feb 5, 2025medical policy review

attachmentadmin note

Coverage Criteria

Non-Reimbursable EIU Criteria

Stance on reimbursement for listed services:

Procedure codes listed in the Non-Reimbursable EIU Services Code List will be denied as non-reimbursable when submitted on a claim; no clinical review is required for those listed codes.

Coding and Code List

Non-reimbursable codesmixedNot Covered

See external attachment

Non-Reimbursable EIU Services Code List (separate attachment) containing CPT Category I, CPT Category III, and HCPCS codes that will be denied.

Clinical review requirement

Clinical review requirementNot required for codes explicitly listed as non-reimbursable; listed CPT Category I, CPT Category III, and HCPCS codes will be denied as non-reimbursable when submitted.

Action on claim submissionProcedure codes included in the Non-Reimbursable EIU Services Code List will be denied as non-reimbursable upon claim submission.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyNon-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

Policy CodePolicy CPCP028

Change TypeAdministrative (code list moved to attachment)

Effective DateMay 15, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation with claims; listed codes in the external code list will be denied as non-reimbursable without clinical review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Claims

Documentation Required

Provider documentation and claim review

Providers are responsible for submitting accurate, complete documentation supporting services rendered. Claims must use valid HIPAA-approved code sets and be coded according to industry-standard coding guidelines (including but not limited to UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI policy manual and CCI edits). Claims are subject to code edit protocols and clinical and administrative review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must furnish additional documentation to support medical necessity and coding. Failure to provide requested documentation may result in denial or recoupment.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines
Claims are subject to code edit protocols, policy and contract review, and coding software logic
Provide additional documentation upon request to support medical necessity and coding

Denial Risk

Automatic denial for listed codes

Certain procedure and service codes identified by the policy as experimental, investigational, or unproven (EIU) are not reimbursable and will be denied without clinical review when submitted on a claim. Refer to the "Non-Reimbursable EIU Services Code List" posted with this policy for the specific CPT Category I, CPT Category III, and HCPCS codes that will be automatically denied. This list is not all-inclusive and denials will be applied in accordance with the member's plan documents.

Automatic denial applies to codes designated as experimental/investigational/unproven (EIU)
Includes CPT Category I, CPT Category III, and HCPCS codes listed on the Non-Reimbursable EIU Services Code List
Denials are applied per the member's plan documents and the posted code list; list may not be all-inclusive

OpenPayer

Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

Coverage Criteria

Coding and Code List

Provider Actions and Claims

Definitions