CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP028

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

Defines procedure and service codes that Blue Cross and Blue Shield of New Mexico will not reimburse because they are deemed experimental, investigational or unproven; applies to providers submitting claims to BCBSNM and members whose coverage is governed by BCBSNM plan documents.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCP028

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionClaims for services listed as EIU will be denied as non-reimbursable when submitted; providers should submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Posted under policyCode list location

01/01/2026Effective date

1.0Version

MultipleUpdate history

Non-Reimbursable EIU Coverage Rules

Covered when the following stance and operational rules apply:

ALL of the following

Stance: Not covered
Procedure codes listed on the Non-Reimbursable EIU Services Code List (including specified CPT Category I, CPT Category III, and HCPCS codes) are denied as non-reimbursable when submitted on a claim based on the member's plan documents.
Clinical review not required for denial
These codes do not require clinical review to determine coverage; denial is applied when submitted.
ALL of the following
- Providers must submit accurate documentation and use valid code combinations per standard coding guidelines (e.g., CPT, HCPCS, ICD-10-CM/PCS, NDCs, CMS CCI and NCCI guidance).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCP028

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

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.

Codes and Applicability

EIU code categoriesCPTExperimental

CPT Category III

Temporary CPT codes intended for data collection for emerging technologies, services, procedures and service paradigms; treated as non-reimbursable under this policy when listed.

Code list applicability — denial when codes enumerated on the Non-Reimbursable EIU Services Code List are submitted

Operational ruleProcedure and service codes enumerated on the Non-Reimbursable EIU Services Code List will be denied as non-reimbursable when submitted on a claim.

Scope of listThe accompanying code list includes CPT Category I codes, CPT Category III codes, and HCPCS codes; the list is maintained separately and may not be all inclusive.

Denial basisCodes are denied because they are determined to be experimental, investigational, or unproven (EIU) per the Coverage Statement and the member's plan documents.

Clinical review requirementThese codes do not require clinical review to determine coverage; denial is applied when submitted.

Claims Submission and Denial Guidance

Denial Risk

Claims for EIU‑listed codes will be denied on submission; submit accurate documentation

Claims for services listed on the Non‑Reimbursable EIU Services Code List will be denied as non‑reimbursable when submitted; providers must submit accurate documentation and may be asked to provide additional documentation upon request. Providers are expected to submit claims using valid code combinations and appropriate coding guidelines; claims are subject to code edit protocols and claim review.

Submit claims using valid code combinations from HIPAA‑approved code sets and follow industry standard coding guidelines (e.g., CPT, HCPCS, ICD‑10‑CM, CCI edits).
Be prepared to provide any additional documentation if requested during claim review.
Claims for CPT Category I, CPT Category III, and HCPCS codes listed on the Non‑Reimbursable EIU Services Code List will be denied when submitted.

Definitions

Experimental/Investigational/Unproven (EIU) — definition

DefinitionServices, procedures or codes determined to be experimental, investigational or unproven (EIU) and therefore non-reimbursable as indicated in the Coverage Statement and accompanying code list.

Effect on claimsEIU-designated services listed on the policy’s code list will be denied as non-reimbursable when submitted on a claim.

Relation to plan documentsNon-reimbursable determination is applied based on the member's plan documents as referenced in the policy.

CPT Category III codes — treatment as EIU when listed

DefinitionCPT Category III codes are temporary CPT codes designated by the AMA for data collection on emerging technologies, services, procedures and service paradigms.

Treatment under policyWhen listed on the Non-Reimbursable EIU Services Code List, CPT Category III codes are treated as non-reimbursable and will be denied when submitted.

Inclusion in code listThe policy’s accompanying list may include CPT Category III codes along with CPT Category I and HCPCS codes; the list is maintained separately.