ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPO28

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

This policy lists procedure, CPT Category III, and HCPCS codes that BCBSNM considers experimental, investigational, or unproven and therefore non-reimbursable when submitted on claims; it applies to claims for BCBSNM members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCPO28

Change TypeCode additions and end-dates

Effective DateSep 27, 2023

Next Review Date

Key ActionSubmit claims using valid HIPAA-approved code sets and provide accurate documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes effective 01/15/2024 and 02/01/2024.

Added HCPCS codes effective 10/01/2023.

End-dated codes 06/30/2023; Added HCPCS codes effective 12/01/2023.

Added HCPCS codes effective 09/01/2023.

Added new CPT/HCPCS codes effective 07/01/2023; revised effective date of CPT/HCPCS codes from 07/01/2023 to 09/01/2023.

100+procedure and temporary codes listed as non-reimbursable in this part

Version 3.0policy version

09/27/2023Medical Policy Review Committee approval date

multipleEntries include EFFECTIVE DATE fields

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.

Coverage Statement and Denial Rules

Denial rule for listed codes

The following services (by CPT/HCPCS/temporary codes and plan addendum entries) are designated non-reimbursable (experimental, investigational, or unproven) and will be denied as not reimbursable when submitted on a claim. These codes do not require individual clinical review to determine non-coverage.

The following code lists are denied as non-reimbursable when submitted on a claim (codes include CPT Category I, CPT Category III, HCPCS, and temporary technology codes).

Code lists include, but are not limited to, the entries enumerated in the plan's reimbursement information and plan addendum below; denial applies per member plan benefits and the payer's code effective dates.

No criteria in this segment

The policy source includes the following reimbursement entries (verbatim excerpts) that represent listed codes and their effective dates. These entries are reproduced for completeness; each line represents a code, description, and effective date as provided by the source.

0435T — PRGRMG EVAL NPGS APNEA 1 SES. Effective date: 04/15/2022.

0436T — PRGRMG EVAL NPGS APNEA STUDY. Effective date: 04/15/2022.

0444T — INITIAL PLACEMENT OF A DRUG ELUTING. Effective date: 12/01/2020 (end date 12/31/2022 noted in source).

0445T — SBSQT PLMT DRUG ELUT OC INS. Effective date: 12/01/2020 (end date 12/31/2022 noted in source).

0464T — VISUAL EP TEST FOR GLAUCOMA. Effective date: 12/01/2020.

A2019 — Kerecis marigen shld sq cm. Effective date: 09/01/2023.

A2020 — Ac5 wound system. Effective date: 09/01/2023.

A2021 — Neomatrix per sq cm. Effective date: 09/01/2023.

A2022 (listed as A2o22) — Innovaburn or innovamatrix xl, per sq cm. Effective date: 10/01/2023.

A2023 — Innovamatrix pd, 1 mg. Effective date: 10/01/2023.

A2024 — Resolve matrix, per sq cm. Effective date: 10/01/2023.

A2025 — Miro3d, per cubic cm. Effective date: 10/01/2023.

A4560 — Nmes disposable. Effective date: 01/15/2024.

A4575 — TOPICAL HYPERBACI OXYGEN CHAMBER D. Effective date: 12/01/2020.

A4596 — Ces system monthly supp. Effective date: 04/01/2023.

A4639 — INFRARED HT SYS REPLCMNT PAD. Effective date: 09/01/2020.

A9291 — Prescription digital behavioral therapy, FDA cleared, per course of treatment. Effective date: 04/01/2022.

C1052 — Hemostatic agent, GI, topical. Effective date: 05/15/2021.

C1823 — GEN, NEURO, TRANS SEN/STIM. Effective date: 04/15/2022.

C1827 — Gen, neuro, imp led, ex cntr. Effective date: 09/01/2023.

C1841 — RETINAL PROSTH INT EXT COMP. Effective date: 12/01/2020 (end date 12/31/2022 noted in source).

C1842 — RETINAL PROSTH ADD ON. Effective date: 12/01/2020 (end date 12/31/2022 noted in source).

C9092 — Injection, triamcinolone acetonide, suprachoroidal (Xipere) 1 mg. Effective date: 04/01/2022 (end date 06/30/2022 noted in source).

C9354 — ACELLULAR PERICARDIAL TISSUE MATRIX. Effective date: 12/01/2020.

C9356 — TENOGLIDE TENDON PROT CM2. Effective date: 12/01/2020.

C9358 — DERMAL SUBSTITUTE NATIVE NON DENA. Effective date: 12/01/2020.

GO281 — ELEC STIM UNATTEND FOR PRESS. Effective date: 09/01/2020.

60282 — ELECT STIM WOUND CARE NOT PD. Effective date: 09/01/2020.

60295 — ELECTROMAGNETIC THERAPY ONC. Effective date: 09/01/2020.

60329 — ELECTROMAGNTIC TX FOR ULCERS. Effective date: 09/01/2020.

60428 — COLLAGEN MENISCUS IMPLANT PROCEDURE. Effective date: 12/01/2020.

60460 — AUTOLOGOUS PRP FOR ULCERS. Effective date: 12/01/2020.

60465 — AUTOLOG PRP DIAB WOUND ULCER. Effective date: 04/15/2022.

69147 — OUTPATIENT INTRAVENOUS INSULIN TREATMENT. Effective date: 12/01/2020.

K1002 — CRANIAL ELECTROTHERAPY STIMULATION. Effective date: 12/01/2020.

K1004 — LO FREQ US DIATHERMY DEVICE. Effective date: 12/01/2020.

Q4258 — Enverse, per square centimeter. Effective date: 04/01/2022.

Q4259 — Celera per sq cm. Effective date: 01/01/2023.

Q4260 — Signature apatch, per sq cm. Effective date: 01/01/2023.

Q4261 — per square centimeter. Effective date: 01/01/2023.

Q4262 — Dual layer impax, per sq cm. Effective date: 01/01/2023.

Q4263 — Surgraft tl, per sq cm. Effective date: 01/01/2023.

Q4264 — Cocoon membrane, per sq cm. Effective date: 01/01/2023.

Q4265 — Neostim tl per sq cm. Effective date: 09/01/2023.

Q4266 — Neostim per sq cm. Effective date: 09/01/2023.

Q4267 — Neostim dl per sq cm. Effective date: 09/01/2023.

Q4268 — Surgraft ft per sq cm. Effective date: 09/01/2023.

Q4269 — Surgraft xt per sq cm. Effective date: 09/01/2023.

Q4270 — Complete sl per sq cm. Effective date: 09/01/2023.

Q4271 — Complete ft per sq cm. Effective date: 09/01/2023.

Q4272 — Esano a, per sq cm. Effective date: 12/01/2023.

Q4273 — Esano aaa, per sq cm. Effective date: 12/01/2023.

Q4274 — Esano ac, per square centimeter. Effective date: 12/01/2023.

Q4275 — Esano aca, per square centimeter. Effective date: 12/01/2023.

Q4276 — Orion, per square centimeter. Effective date: 12/01/2023.

Q4277 — Woundplus membrane or e-graft, per square centimeter. Effective date: 12/01/2023.

Q4278 — Epieffect, per square centimeter. Effective date: 12/01/2023.

Q4280 — Xcell amnio matrix, per square centimeter. Effective date: 12/01/2023.

Q4281 — Barrera sl or barrera dl, per square centimeter. Effective date: 12/01/2023.

Q4282 — Cygnus dual, per square centimeter. Effective date: 12/01/2023.

Q4284 — Dermabind sl, per square centimeter. Effective date: 12/01/2023.

Q4285 — Nudyn dl or nudyn dl mesh, per sq cm. Effective date: 10/01/2023.

S2117 — ARTHROEREISIS SUBTALAR. Effective date: 12/01/2020.

S2300 — ARTHROSCOPY SHOULDER SURGI. Effective date: 12/01/2020.

S3650 — SALIVA TEST HORMONE LEVEL DURING. Effective date: 12/01/2020.

S3652 — SALIVA TEST HORMONE LEVEL TO ASSE. Effective date: 12/01/2020.

S3900 — SURFACE EMG. Effective date: 09/01/2020.

S8130 — INTERFERENTIAL STIM 2 CHAN. Effective date: 09/01/2020.

S8131 — INTERFERENTIAL STIM 4 CHAN. Effective date: 09/01/2020.

S8940 — HIPPOTHERAPY PER SESSION. Effective date: 09/01/2020.

S9001 — HOME UTERINE MONITOR WITH OR. Effective date: 09/01/2020.

S9056 — COMA STIMULATION PER DIEM. Effective date: 12/01/2020.

S9090 — VERTEBRAL (entry truncated in source).

Code listings and plan addendum

The plan addendum contains additional code-to-plan mappings and BIT429 plan flags (per-state columns). Excerpts from the plan addendum are provided below; presence in the addendum indicates the code may be subject to plan-specific denial when BIT429 is enabled for that plan.

E1700 — JAW MOTION REHAB SYSTEM. BIT429 mapping: IL = X; OK = X. Effective date: 12/01/2020 addendum entry.

E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. BIT429 mapping: IL = X. Effective date: 12/01/2020 addendum entry.

J7604 — ACETYLCYSTEINE COMP UNIT. Plan addendum columns indicate no NM flag on source excerpt.

J7607 — LEVALBUTEROL COMP CON. Plan addendum columns indicate no NM flag on source excerpt.

J7609 — ALBUTEROL COMP UNIT. Plan addendum columns indicate no NM flag on source excerpt.

Code Lists and Effective Dates

Sample of listed non-reimbursable procedure codesCPTNot Covered

17340	CRYOTHERAPY OF SKIN
20560	NDL INSJ W 0 NJX 1 OR 2 MUSC
22526	IDET SINGLE LEVEL
22867	INSJ STABLJ DEV W/DCMPRN
28890	HI ENRGY ESWT PLANTAR

Sample code list present in this segmentmixed

0435T	PRGRMG EVAL NPGS APNEA 1 SES
0444T	INITIAL PLACEMENT OF A DRUG ELUTING
0766T	TC MAG STIMJ PN 1ST TX 1NRV
A2001	Innovamatrix ac, per sq cm
A4560	Nmes disposable
A9291	Prescription digital behavioral therapy, fda cleared, per course f treatment
C1823	GEN, NEURO, TRANS SEN/STIM
E0231	WOUND WARMING DEVICE
K1023	Trans elec nerv periph nerv

sample codes from start of listmixedCovered

GO281	ELEC STIM UNATTEND FOR PRESS.
60282	ELECT STIM WOUND CARE NOT PD.
60295	ELECTROMAGNETIC THERAPY ONC.
60329	ELECTROMAGNTIC TX FOR ULCERS.
60428	COLLAGEN MENISCUS IMPLANT PROCEDURE.
60460	AUTOLOGOUS PRP FOR ULCERS.
60465	AUTOLOG PRP DIAB WOUND ULCER.
69147	OUTPATIENT INTRAVENOUS INSULIN TREATMENT.
K1002	CRANIAL ELECTROTHERAPY STIMULATION.
K1004	LO FREQ US DIATHERMY DEVICE.

biologic/amniotic/graft products (sample)HCPCSCovered

Q4103	Oasis burn matrix.
Q4104	Integra BMWD.
Q4110	Primatrix.
Q4115	Alloskin.
Q4122	Dermacell, awm, porous sq cm.

additional graft/amniotic codesHCPCSCovered

Q4210	AXOLOTL GRAFT OR AXOLOTL DUALGRAFT.
Q4224	Human health factor 10 amniotic patch (hhf10-p) per square centimeter.
Q4234	XCELLERATE, PER SQUARE CENTIMETER.
Q4240	CORECYTE, FOR TOPICAL USE ONLY, PER.

Listed HCPCS/S codes and descriptionsHCPCS

Q4258	Enverse, per square centimeter
Q4259	Celera per sq cm
Q4260	Signature apatch, per sq cm
Q4262	Dual layer impax, per sq cm
Q4263	Surgraft tl, per sq cm
Q4272	Esano a, per square centimeter
Q4273	Esano aaa, per sq cm
Q4280	Xcell amnio matrix, per square centimeter
Q4285	Nudyn dl or nudyn dl mesh, per sq cm
S2117	ARTHROEREISIS SUBTALAR

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Effective date presence

SummaryMost reimbursement code entries in the policy include an EFFECTIVE DATE; many END DATE fields are blank (no termination date).

Example effective datesA9291 EFFECTIVE DATE = 04/01/2022; A2019 EFFECTIVE DATE = 09/01/2023; Q4258 EFFECTIVE DATE = 04/01/2022.

Example missing end dates0435T END DATE = . (blank); A2019 END DATE = . (blank); Q4262 END DATE = . (blank).

effective_date_range_present

Presence of effective date rangeEntries show EFFECTIVE DATE values spanning 2020–2023 (examples: GO281 EFFECTIVE DATE = 09/01/2020; Q4262 EFFECTIVE DATE = 01/01/2023).

Billing, Claims Submission, and Provider Responsibilities

Documentation Required

Provider claim submission and documentation responsibilities

Providers are responsible for submitting accurate documentation of services performed and must submit claims using valid HIPAA‑approved code sets. Claims are subject to claim review and providers may be asked to submit additional documentation upon request.

Submit claims using valid HIPAA‑approved code sets and appropriate code combinations.
Be prepared to provide additional documentation when requested for claim review.

Note

Reimbursement code listings (no auth details)

The document lists CPT, HCPCS and T‑code entries with descriptions and EFFECTIVE/END DATE fields; this segment does not include prior authorization instructions.

Codes shown include 0435T, 0436T, 0444T, 0445T, 0464T with EFFECTIVE DATE and END DATE fields.
No prior authorization or clinical review requirements are specified in this listing.

Key Terms and Field Definitions

EIU

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

Policy implicationCodes determined EIU are denied as non-reimbursable when submitted on a claim to BCBSNM.

Code sets coveredIncludes CPT Category I, CPT Category III (temporary) and HCPCS codes listed in the policy.

Date the code entry became effective

Field nameEFFECTIVE DATE = Date the code entry became effective (when the reimbursement entry became active).

Examples0435T EFFECTIVE DATE = 04/15/2022; A2019 EFFECTIVE DATE = 09/01/2023; GO281 EFFECTIVE DATE = 09/01/2020.