CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP028

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

This Clinical Payment and Coding Policy (CPCP028) lists procedure codes (CPT/HCPCS/Category III) that BCBSNM deems experimental, investigational, or unproven and therefore non-reimbursable when submitted on claims; it applies to providers submitting claims under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCP028

Change TypeCode additions and end-dates

Effective DateJan 15, 2024

Next Review Date

Key ActionSubmit claims using valid HIPAA-approved code sets and include accurate supporting documentation; claims for codes listed as experimental/investigational/unproven will be denied as non-reimbursable.

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.

2024-01-15effective date

3.0version

50+procedure codes listed

Multipleentries with open end date

2019-2024

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 Criteria — Non‑Reimbursable Codes

Non-reimbursable codes and reimbursement stance

The Coverage Statement identifies codes that are not reimbursable because they are experimental, investigational, or unproven. The list includes CPT Category I codes, HCPCS, and CPT Category III codes which will be denied as non-reimbursable when submitted on a claim.

Codes explicitly determined to be experimental, investigational, or unproven are not reimbursable and will be denied when submitted on a claim (no clinical review required).

CPT / HCPCS / Category III Codes

Listed non-reimbursable procedure codes (examples from document)mixedNot Covered

17340	CRYOTHERAPY OF SKIN
22526	IDET SINGLE LEVEL
28890	HI ENERGY ESWT PLANTAR FASCIA
36473	ENDOVENOUS MCHNCHEM 1ST VEIN
91111	ESOPHAGEAL CAPSULE ENDOSCOPY
0052U	LIPOPROTEIN BLOOD WITH 5 MAJOR CLASSES (example listed)

Sample T-codesCPT

0433T	REPOS NSTIM APNEA SENSING LD
0434T	INTERRO EVAL NPGS APNEA
0435T	PRGRMG EVAL NPGS APNEA 1 SES

Sample A/C codesHCPCS

A2001	Innovamatrix ac, per sq cm
A4560	Nmes disposable
C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg
A9291	Prescription digital behavioral therapy, fda cleared, per course of treatment

Examples from start of listHCPCS

G0255	CURRENT PERCEP THRESHOLD TST
G0281	ELEC STIM UNATTEND FOR PRESS
G0282	ELECT STIM WOUND CARE NOT PD

Example K-codesHCPCS

K1002	CRANIAL ELECTROTHERAPY STIMULATION
K1004	LO FREQ US DIATHERMY DEVICE
K1007	Bil hkaf pc s/d micro sensor

Example Q-codes (biologic/wound matrices)HCPCS

Q4103	Oasis burn matrix
Q4122	Dermacell, awm, porous sq cm
Q4259	Celera per sq cm

Listed CPT/HCPCS codes and descriptionsHCPCS

Q4257	Relese, per square centimeter. Effective 04/01/2022
Q4258	Enverse, per square centimeter. Effective 04/01/2022
Q4259	Celera per sq cm. Effective 01/01/2023
Q4260	Signature apatch, per sq cm. Effective 01/01/2023
Q4261	Tag, per square centimeter. Effective 01/01/2023
Q4262	Dual layer impax, per sq cm. Effective 01/01/2023
Q4263	Surgraft tl, per sq cm. Effective 01/01/2023
Q4264	Cocoon membrane, per sq cm. Effective 01/01/2023
Q4265	Neostim tl per sq cm. Effective 09/01/2023
Q4266	Neostim per sq cm. Effective 09/01/2023

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Reimbursement stance

Reimbursement stanceCodes explicitly determined to be experimental, investigational, or unproven (EIU) — including CPT Category I, HCPCS, and CPT Category III codes — will be denied as non-reimbursable when submitted on a claim.

Claims handlingDenial occurs without requirement for clinical review when code is listed as EIU in the Coverage Statement.

Applicable code setsApplies to CPT Category I, CPT Category III (temporary/T-codes), and HCPCS codes listed in the policy.

End dates present for some codes

Presence of end datesSome listed codes include explicit end dates (example: K1024 end date 06/30/2023).

Open-ended entriesMany entries show an EFFECTIVE DATE with no END DATE (remain open-ended until updated).

Implication for billingProviders should verify code effective/end dates before claim submission to confirm current applicability.

Policy update entries

Recent update summaryPolicy Update History documents additions and end-dating of CPT/HCPCS codes from 2020 through 2024 (e.g., added codes effective 01/15/2024 and 02/01/2024).

End-dating actionsEntries include specific end-dating events (for example: end-dated codes 06/30/2023; end-dated codes 12/31/2022).

Frequency of updatesMultiple update entries recorded across 2021–2024 indicating periodic additions and removals of codes.

Provider Responsibilities & Billing Guidance

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 should be coded according to industry-standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI). Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support services billed.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.).
Provide supporting documentation upon request to substantiate medical necessity and coding.
Claims are subject to code-edit protocols and review against plan and contract terms.

Definitions and Coding Glossary

EIU

DefinitionNon-reimbursable Experimental, Investigational and/or Unproven Services (EIU): Services/procedure codes explicitly determined to be experimental, investigational, or unproven and denied without clinical review.

ScopeIncludes procedure codes or categories of codes listed in the Coverage Statement that do not require clinical review to determine coverage.

Effect on claimsCodes designated EIU will be denied as non-reimbursable when submitted on a claim.

Temporary CPT Category III code used for emerging technologies, procedures, and services

DefinitionT-code: Temporary CPT Category III code used for emerging technologies, procedures, and services.

Example range

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCP028

Change TypeCode additions and end-dates

Effective DateJan 15, 2024

Next Review Date

SourceLink

On This Page

Billing Rule

T-code reimbursement entries (partial)

Reimbursement entries for temporary (T) HCPCS codes listed below are recognized with the noted effective dates. Providers must bill using the exact T-code and ensure documentation supports the service described by the code.

0433T — REPOS NSTIM APNEA SENSING LD. Effective 04/15/2022.
0434T — INTERRO EVAL NPGS APNEA. Effective 04/15/2022.
0435T — PRGRMG EVAL NPGS APNEA 1 SES. Effective 04/15/2022.
0436T — PRGRMG EVAL NPGS APNEA STUDY. Effective 04/15/2022.
0444T — INITIAL PLACEMENT OF A DRUG ELUTING. Effective 12/01/2020 (end-dated 12/31/2022).
0445T — SBSQT PLMT DRUG ELUT OC INS. Effective 12/01/2020 (end-dated 12/31/2022).
0464T — VISUAL EP TEST FOR GLAUCOMA. Effective 12/01/2020.

Billing Rule

A/C/other HCPCS code reimbursement entries (partial)

Reimbursement entries for A-, C-, and other permanent HCPCS codes listed below are recognized with the noted effective dates. Bill the exact HCPCS code and include appropriate quantity and modifier usage per standard billing practice. Ensure documentation demonstrates the item(s) or service(s) billed (e.g., square centimeters for wound matrices, monthly supplies, disposables).

0782T — BRNCHSC RF DSTRJ PLM NRV UNI. Effective 09/01/2023.
0783T — TRANSCUT AURICULAR NEUROSTIM. Effective 01/01/2023.
0791T — MOTR COG VR GAIT TRAIN EA 15. Effective 07/01/2023.
0807T — PULM TISS VNTJ ALYS PREV CT. Effective 07/01/2023.
0808T — PULM TISS VNTJ ALYS W/CT. Effective 07/01/2023.
0809T — ARTHRD SI JT PRQ TFX&IMPLT. Effective 12/01/2023.
A2001 — Innovamatrix ac, per sq cm. Effective 04/15/2022.
A2002 — Mirragen adv wnd mat per sq. Effective 04/15/2022.
A2004 — Xcellistem, per sq cm. Effective 04/15/2022.
A2005 — Microlyte matrix, per sq cm. Effective 04/15/2022.
A2006 — Novosorb synpath per sq cm. Effective 04/15/2022.
A2007 — Restrata, per sq cm. Effective 04/15/2022.
A2008 — Theragenesis, per sq cm. Effective 04/15/2022.
A2009 — Symphony, per sq cm. Effective 04/15/2022.
A2010 — Apis, per square centimeter. Effective 04/15/2022.
A2011 — Supra sdrm, per square centimeter. Effective 04/01/2022.
A2012 — Suprathel, per square centimeter. Effective 04/01/2022.
A2013 — Innovamatrix fs, per square centimeter. Effective 04/01/2022.
A2014 — Omeza collag per 100 mg. Effective 04/01/2023.
A2015 — Phoenix wnd mtrx, per sq cm. Effective 04/01/2023.
A2016 — Permeaderm b, per sq cm. Effective 04/01/2023.
A2017 — Permeaderm glove, each. Effective 04/01/2023.
A2018 — Permeaderm c, per sq cm. Effective 04/01/2023.
A2019 — Kerecis marigen shld sq cm. Effective 09/01/2023.
A2020 — Ac5 wound system. Effective 09/01/2023.
A2021 — Neomatrix per sq cm. Effective 09/01/2023.
A2022 — Innovaburn or innovamatrix xl, per sq cm. Effective 10/01/2023.
A2023 — Innovamatrix pd, 1 mg. Effective 10/01/2023.
A2024 — Resolve matrix, per sq cm. Effective 10/01/2023.
A2025 — Miro3d, per cubic cm. Effective 10/01/2023.
A4560 — Nmes disposable. Effective 01/15/2024.
A4575 — TOPICAL HYPERBACI OXYGEN CHAMBER D. Effective 12/01/2020.
A4596 — Ces system monthly supp. Effective 04/01/2023.
G0255 — CURRENT PERCEP THRESHOLD TST. Effective 09/01/2020.
G0281 — ELEC STIM UNATTEND FOR PRESS. Effective 09/01/2020.
G0282 — ELECT STIM WOUND CARE NOT PD. Effective 09/01/2020.
G0295 — ELECTROMAGNETIC THERAPY ONC. Effective 09/01/2020.
G0329 — ELECTROMAGNTIC TX FOR ULCERS. Effective 09/01/2020.
G0428 — COLLAGEN MENISCUS IMPLANT PROCEDURE. Effective 12/01/2020.
G0460 — AUTOLOGOUS PRP FOR ULCERS. Effective 12/01/2020.
G0465 — AUTOLOG PRP DIAB WOUND ULCER. Effective 04/15/2022.
G9147 — OUTPATIENT INTRAVENOUS INSULIN TREATMENT. Effective 12/01/2020.
K1002 — CRANIAL ELECTROTHERAPY STIMULATION. Effective 12/01/2020.

Note

Code update notifications

Codes and their effective dates are periodically updated; providers should refer to the policy update history for code additions and end-dates and confirm billing requirements at time of service. If a listed code has an end date noted, it may no longer be reimbursable after that date.

Policy Update History shows recurring additions and end-dates for CPT/HCPCS codes; verify code effective/end dates before billing.
Examples: added HCPCS codes effective 01/15/2024 and 02/01/2024; multiple additions effective 07/01/2023, 09/01/2023, 10/01/2023, 12/01/2023.

Document lists numerous T-codes with EFFECTIVE DATE and END DATE fields (examples include 0433T, 0444T, 0782T, 0809T).

Billing noteT-codes included in the list are treated per the policy’s reimbursement stance (may be denied if listed as EIU).

Healthcare Common Procedure Coding System codes for supplies, devices, and procedures

DefinitionHCPCS codes: Healthcare Common Procedure Coding System codes used for supplies, devices, and procedures (A-, C-, G-, K-, Q-, etc.).

Examples in policyExamples include A2001 (Innovamatrix), G0255 (CURRENT PERCEP THRESHOLD TST), and numerous Q-prefixed wound/biologic codes with effective dates.

Effective/end datesHCPCS entries in the policy include EFFECTIVE DATE and, where provided, END DATE fields for billing reference.

Reimbursement Information entry

Entry formatReimbursement Information lines include code, description, EFFECTIVE DATE, and END DATE where provided.

PurposeServes as the policy’s list for billing/reimbursement reference and indicates when codes were added or removed.

Provider actionProviders should reference these entries to determine whether a code is listed and its effective/end dating before claim submission.

CPT/HCPCS trademark and term note

CPT trademarkCPT is a registered trademark of the American Medical Association (AMA).

HCPCS termHCPCS stands for Healthcare Common Procedure Coding System.