CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO28

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

This policy lists procedure, CPT Category III and HCPCS codes that Blue Cross Blue Shield of New Mexico deems non-reimbursable as experimental, investigational, or unproven and governs claim adjudication for affected members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCPO28

Change TypeNo material change

Effective DateJun 21, 2024

Next Review Date

Key ActionSubmit claims using valid HIPAA code sets and provide accurate documentation; BCBSNM may request additional documentation for claim adjudication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+codes listed (non-reimbursable)

3.0policy version

06/21/2024committee approval

somecodes with end dates

Non‑Reimbursable and Reimbursement Code Listings

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.

Non-reimbursable codes (partial list in this document part)

The following procedure, CPT Category III and HCPCS codes are identified as not reimbursable and do not require additional clinical review to determine coverage.

Codes listed below are considered non-reimbursable (experimental, investigational, and/or unproven) and will be denied when submitted on a claim per the policy statement.

Examples of non-reimbursable procedure/CPT/HCPCS codes (partial list)

17340 — CRYOTHERAPY OF SKIN
20560 — Needle injection (percutaneous) (description truncated in source)
22526 — IDET single level
22836 — Anterior thoracic vertebral body tethering (<7)
33276 — Insertion of phrenic nerve stimulator system
28890 — High energy ESWT plantar fascia
36473 — Endovenous mechano-chemical, first vein
86328 — IA NFCT AB SARS‑CoV‑2 COVID19

Codes and Dates (informational)

Code list entries include descriptions and EFFECTIVE DATE / END DATE fields as shown in the document.

Sample temporary CPT Category III (T) and related entries

0274T — PERQ LAMOTILAM CRVITHRC; EFFECTIVE DATE = 01/01/2023; END DATE = (blank)
0275T — PERQ LAMOTILAM LUMBAR; EFFECTIVE DATE = 01/01/2023; END DATE = (blank)
0278T — TEMPR; EFFECTIVE DATE = 12/01/2020; END DATE = (blank)
0330T — TEAR FILM IMG UNI/BI W/&R; EFFECTIVE DATE = 09/01/2020; END DATE = (blank)
0322U — NEURO ASD MEAS 14 ACYL CARN; EFFECTIVE DATE = 02/01/2024; END DATE = (blank)

Code listings only

List of codes with descriptions and effective/end dates; no explicit coverage criteria or utilization management rules provided in this excerpt.

Selected code listings (examples)

C9358 — (listed); EFFECTIVE DATE = 12/01/2020; END DATE = (blank)
C9363 — Integra Meshed Bil Wound Mat; EFFECTIVE DATE = 05/15/2021; END DATE = (blank)
C9364 — PORCINE IMPLANT PERMACOL; EFFECTIVE DATE = 12/01/2020; END DATE = (blank)
C9757 — Spine/lumbar disk surgery; EFFECTIVE DATE = 08/01/2022; END DATE = (blank)
Q4103 — Oasis burn matrix; EFFECTIVE DATE = 05/15/2021; END DATE = (blank)
Q4104 — Integra BMWD; EFFECTIVE DATE = 05/15/2021; END DATE = (blank)
Q4110 — Primatrix; EFFECTIVE DATE = 05/15/2021; END DATE = (blank)
Q4111 — Gammagraft; EFFECTIVE DATE = 05/15/2021; END DATE = (blank)

Plan addendum applicability

Plan addendum BIT429 flags indicate whether a code is active for that plan/state (an 'X' in the column indicates BIT429 ON for that plan).

ANY of the following

E1700 — JAW MOTION REHAB SYSTEM; BIT429 flag = X (general column); NM column = (blank); END DATE = 06/30/2024
E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION; BIT429 flag = X (general column); OK column = X; NM column = (blank); END DATE = 06/30/2024
J7604 — ACETYLCYSTEINE COMP UNIT; BIT429 flag = X (general column); NM column indicated with an 'x' in table; END DATE = (blank)
J7607 — LEVALBUTEROL COMP CON; BIT429 flag = (blank) in these chunks; END DATE = (blank)

Code Tables and Coding Details

Sample of listed non-reimbursable procedure and lab codes (partial list)mixedNot Covered

17340	CRYOTHERAPY OF SKIN
20560	Needle injection (percutaneous) (description truncated in source)
22526	IDET single level
22836	Anterior thoracic vertebral body tethering (<7)
33276	Insertion of phrenic nerve stimulator system
28890	High energy ESWT plantar fascia
36473	Endovenous mechano-chemical, first vein
86328	IA NFCT AB SARS-CoV-2 COVID19

Example temporary CPT Category III (T) codesCPT

0274T	PERQ LAMOTILAM CRVITHRC
0275T	PERQ LAMOTILAM LUMBAR
0278T	TEMPR

Example HCPCS A-codes (wound matrices, devices)HCPCS

A2002	Mirragen adv wnd mat per sq.
A2012	Suprathel, per square centimeter
A4540	Trans elec nerv periph nerv

Mixed HCPCS/C-codes/E-codesmixed

A9291	Prescription digital behavioral therapy, fda cleared, per course of treatment
C1832	Auto cell process sys
E0487	ELECTRONIC SPIROMETER

Sample Q-codes for biologic matricesHCPCSCovered

Q4103	Oasis burn matrix
Q4104	Integra BMWD
Q4110	Primatrix
Q4111	Gammagraft

Amniotic and injectable biologic codesHCPCSCovered

Q4137	AMNIOEXCEL BIODEXCEL 1SQ CM
Q4145	EPIFIX, INJECTABLE, MG
Q4148	NEOX 1K PER SQUARE CENTIMETER

Example Q-codes (amniotic/skin graft products)HCPCSCovered

Q4215	AXOLOTL AMBIENT OR AXOLOTL CRYO (per unit/sq cm)
Q4216	ARTACENT CORD, PER SQUARE CENTIMETER
Q4217	WOUNDFIX, BIOWOUND; WOUNDFIX PLUS

Additional Q-codes with effective datesHCPCSCovered

Q4259	Celera per sq cm (eff 01/01/2023)
Q4280	Xcell amnio matrix, per square centimeter (eff 12/01/2023)
Q4311	Acesso, per sq cm (eff 07/01/2024)

Jaw motion device codesHCPCS

E1700	JAW MOTION REHAB SYSTEM
E1701	REPLACEMENT CUSHIONS FOR JAW MOTION
E1702	REPL MEASR SCALES JAW MOTION

Inhalation/respiratory J-codesHCPCS

J7604	ACETYLCYSTEINE COMP UNIT
J7607	LEVALBUTEROL COMP CON
J7609	ALBUTEROL COMP UNIT
J7622	BECLOMETHASOME INHALATION SOLUTION
J7624	BETAMETHASOME INHALATION SOLUTION
J7627	BUDESONIDE COMP UNIT
J7628	BITOLTEROL MESYLATE, INHALATION SOL
J7629	BITOLTEROL MESYLATE INHALATION SOL
J7632	CROMOLYN SODIUM COMP UNIT
J7634	BUDESONIDE INHALATION SOLUTION CO

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inv-16: codes with explicit end-date until 12/31/2023

Example codes with END DATE = 12/31/20230424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T (each shows END DATE = 12/31/2023)

Additional code with END DATE = 12/31/2023C9771 (END DATE = 12/31/2023)

Context noteThese END DATE entries appear in the reimbursement listings and indicate plan-level end dates for those temporary codes.

inv-17: Effective date presence — many codes show EFFECTIVE DATE entries

Presence of EFFECTIVE DATE fieldsMany listed codes include an EFFECTIVE DATE entry (examples: 0274T EFFECTIVE DATE = 01/01/2023; 0330T EFFECTIVE DATE = 09/01/2020; Q4192 EFFECTIVE DATE = 12/01/2020)

Varied effective datesEffective dates in the document range across years (e.g., 2020, 2021, 2022, 2023, 2024) and are shown per code line.

Some EFFECTIVE DATE fields blankA few code lines show EFFECTIVE DATE fields left blank in the reimbursement listings.

inv-18: per square centimeter pricing unit — many listed products are reimbursed per square centimeter

Per square centimeter pricing examplesA2012 (Suprathel), A2004 (Xcellistem), A2006 (Novosorb) and many Q-codes (e.g., Q4219, Q4221, Q4222) are listed with pricing unit 'per square centimeter' or similar

Multiple Q-code examples priced per sq cmQ4193 (Coll-e-derm 1 sq cm), Q4219 (SURGIGRAFT-DUAL, per square centimeter), Q4295 (Amnio tri-core, per sq cm)

Document conventionThe reimbursement listings consistently use 'per square centimeter' for numerous biologic/amniotic matrix product entries.

Provider Responsibilities and Plan Addendum Notes

Documentation Required

Provider claim submission and documentation responsibilities

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claims are subject to review against benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, coding software logic, and industry-standard coding guidelines. Upon request, providers should furnish supporting documentation to substantiate services billed.

Submit claims using current HIPAA code sets (CPT, HCPCS, ICD-10, NDC, Revenue, DRG).
Be prepared to provide supporting clinical documentation upon request to avoid denials or recoupment.

Billing Rule

Reimbursement code listing (no authorization details)

Reimbursement code listing (selection — no prior authorization information). The plan lists numerous HCPCS/CPT/U-codes with descriptions and effective dates. Examples below are representative entries from the reimbursement listing; this is a consolidated, non-exhaustive excerpt and contains no prior authorization details.

0274T — PERQ LAMOTILAM CRVITHRC. Effective Date: 01/01/2023.
0275T — PERQ LAMOTILAM LUMBAR. Effective Date: 01/01/2023.
0278T — TEMPR. Effective Date: 12/01/2020.
0330T — TEAR FILM IMG UNI/BI W/&R. Effective Date: 09/01/2020.
0322U — NEURO ASD MEAS 14 ACYL CARN. Effective Date: 02/01/2024.
C9358 — (dena). Effective Date: 12/01/2020.
C9363 — Integra Meshed Bil Wound Mat. Effective Date: 05/15/2021.
C9364 — PORCINE IMPLANT PERMACOL. Effective Date: 12/01/2020.
C9757 — Spine/lumbar disk surgery. Effective Date: 08/01/2022.
C9768 — porto hep grad. Effective Date: 03/01/2021.
C9771 — Nsl/sins cryo post nasal tis. Effective Date: 07/15/2021. End Date: 12/31/2023.
Q4333 — Ardeograft, per sq cm. Effective Date: 07/01/2024.

Billing Rule

S-code reimbursement listings

S-code reimbursement listings (examples). The plan reimbursement list includes multiple S-codes with descriptions and effective dates; this block highlights representative S-code entries.

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.

Note

Plan addendum flags (BIT429) and example codes — jaw motion devices; respiratory / inhalation solution codes

Plan addendum BIT429 flags and respiratory/inhalation solution codes. BIT429 indicates plan-specific applicability (an 'X' in a plan column means BIT429 is ON for that plan). The addendum includes jaw motion device codes and numerous J-/J76xx inhalation solution codes with plan-level X flags (New Mexico and other states shown in source). Examples below consolidate those entries.

E1700 — JAW MOTION REHAB SYSTEM. BIT429 = X. End Date: 06/30/2024.
E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. BIT429 = X (some plans). End Date: 06/30/2024.
J7604 — ACETYLCYSTEINE COMP UNIT. BIT429 = X (some plans); NM column shown as 'x' in source.
J7607 — LEVALBUTEROL COMP CON. BIT429 flag blank in source.
J7609 — ALBUTEROL COMP UNIT. BIT429 flag blank in source.
J7622 — BECLOMETHASONE INHALATION SOLUTION. BIT429 flag blank in source.
J7624 — BETAMETHASONE INHALATION SOLUTION. BIT429 = X for some plans; TX column indicated X in source.
J7627 — BUDESONIDE COMP UNIT. BIT429 = X for some plans.
J7628 / J7629 — BITOLTEROL MESYLATE INHALATION SOLUTIONS. J7628/J7629 show BIT429 = X for some plans; J7629 also shows TX = X in source.
J7632 — CROMOLYN SODIUM COMP UNIT. BIT429 = X for some plans; TX column indicated X.
J7634 — BUDESONIDE INHALATION SOLUTION CO. BIT429 = X for some plans.

Definitions and Coding Glossary

inv-26: EIU — Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

Definition (EIU)Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU): services and codes determined to be experimental, investigational, or unproven and therefore not reimbursable under the policy.

ScopeIncludes CPT Category III (temporary) codes, HCPCS and other procedure codes that will be denied as non-reimbursable when submitted on a claim.

Adjudication implicationThese codes do not require additional clinical review to determine coverage and are denied based on the member's plan document.

inv-27: Reimbursement Information (definition entry)

TermReimbursement Information

Usage in documentStructured lines list code, description, EFFECTIVE DATE and END DATE for each reimbursement entry.

PurposeProvides the code-level entries used to determine non-reimbursable services in the policy sections.

inv-28: Reimbursement Information — structured lines showing code, description, EFFECTIVE DATE, and END DATE

Typical line structureExample: '0274T, EFFECTIVE DATE = 01/01/2023. 0274T, END DATE = .', i.e., code, EFFECTIVE DATE, END DATE shown per line.

Sample code lines0397T, EFFECTIVE DATE = 09/01/2020. 0424T, EFFECTIVE DATE = 04/15/2022. 0424T, END DATE = 12/31/2023.

Q-code line exampleQ4192, EFFECTIVE DATE = 12/01/2020. Q4192, END DATE = .

inv-29: Healthcare Common Procedure Coding System HCPCS

AcronymHCPCS — Healthcare Common Procedure Coding System

Document referenceHCPCS is referenced as the coding system used for many listed products (Q-, J-, A-, E-, S-codes) in the reimbursement listings.

Standards noteHCPCS codes appear throughout the policy's reimbursement information and addendum tables.

inv-30: Current Procedural Terminology (AMA) — CPT

AcronymCPT — Current Procedural Terminology (AMA)

UsageCPT and CPT Category III (temporary/T) codes are included in the policy's non-reimbursable code lists.

Source attributionCPT is a registered trademark of the AMA as noted in the document.

inv-31: BIT429 — flag 'X' indicates the BIT429 setting is ON for that plan/column

BIT429 flag meaningAn 'X' in the BIT429 column indicates the BIT429 setting is ON for that plan/column (plan addendum).

ExampleE1700 shows '= X' in the BIT429 general column in the plan addendum table.

Operational impactBIT429 flags denote plan-specific applicability of listed codes in the addendum table.

inv-32: END DATE — field indicates plan-specific end date for the code's addendum entry

Field purposeEND DATE field indicates a plan-specific end date for the code's addendum entry in the plan addendum table.

Example entriesE1700 END DATE = 06/30/2024; E1701 END DATE = 06/30/2024; some J-codes show END DATE = . (blank)

InterpretationWhen populated, END DATE denotes the last date the code is effective for that plan column in the addendum.