CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP028

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

Lists procedure and test codes that BCBSNM designates as experimental, investigational or unproven and therefore not reimbursable when submitted on a claim; 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 TypeNo material changes

Effective DateJan 15, 2024

Next Review DateN/A

Key ActionSubmit claims using valid HIPAA code sets and note that listed codes are denied as non-reimbursable without clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozensnon-reimbursable codes

3.0policy version

deny w/o reviewprocessing stance

A4560 01/15/24most recent code eff date

NM flaggedNM plan flag

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.

inv-01: Non‑reimbursable codes — Coverage stance for codes listed in this policy

Covered when the following policy statement applies:

Codes explicitly listed in this policy are determined to be experimental, investigational or unproven and are non‑reimbursable when submitted on a claim.

Listed codes do not require clinical review to determine coverage; they will be denied as non‑reimbursable under BCBSNM plans.

inv-02: Codes identified by the policy — enumerated codes and descriptions in reimbursement section (presumed non-reimbursable/experimental)

The policy identifies the following codes and descriptions in its reimbursement section (entries include effective dates and, where applicable, end dates):

Examples

0435T — PRGRMG EVAL NPGS APNEA 1 SES. (Effective 04/15/2022)
0444T — INITIAL PLACEMENT OF A DRUG ELUTING. (Effective 12/01/2020, End Date 12/31/2022)
A9291 — Prescription digital behavioral therapy, fda cleared, per course of treatment. (Effective 04/01/2022)
C9092 — Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg. (Effective 04/01/2022, End Date 06/30/2022)
G0255 — CURRENT PERCEP THRESHOLD TST. (Effective 09/01/2020)
G0465 — AUTOLOG PRP DIAB WOUND ULCER. (Effective 04/15/2022)
K1002 — CRANIAL ELECTROTHERAPY STIMULATION. (Effective 12/01/2020)
P9020 — PLAELET RICH PLASMA UNIT. (Effective 12/01/2020)

inv-03: Enumerated non-reimbursable codes (partial) — HCPCS and other codes with prefixes G-, K-, L-, M-, P-, Q- and others

Partial enumeration of HCPCS and other codes (G-, K-, L-, M-, P-, Q- and others) listed in the policy with descriptions and effective dates:

G- and K- codes (sample)

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)
K1002 — CRANIAL ELECTROTHERAPY STIMULATION. (Effective 12/01/2020)

Code Examples and Effective Dates

Examples from non‑reimbursable listmixedNot Covered

17340	CRYOTHERAPY OF SKIN
22526	IDET SINGLE LEVEL
28890	HI ENRGY ESWT PLANTAR FASCIA

Examples from reimbursement listmixedExperimental

0435T	PRGRMG EVAL NPGS APNEA 1 SES.
0444T	INITIAL PLACEMENT OF A DRUG ELUTING.
A4560	Nmes disposable.
A9291	Prescription digital behavioral therapy, fda cleared, per course of treatment.
C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg.
E1632	Wearable artificial kidney.
G0465	AUTOLOG PRP DIAB WOUND ULCER.
K1018	Ext up limb tremor stim wris

sample_code_listHCPCSNot Covered

G0255	CURRENT PERCEP THRESHOLD TST
G0281	ELEC STIM UNATTEND FOR PRESS
G0282	ELECT STIM WOUND CARE NOT PD
G0295	ELECTROMAGNETIC THERAPY ONC
G0329	ELECTROMAGNTIC TX FOR ULCERS
G0428	COLLAGEN MENISCUS IMPLANT PROCEDURE
G0460	AUTOLOGOUS PRP FOR ULCERS
G0465	AUTOLOG PRP DIAB WOUND ULCER
G9147	OUTPATIENT INTRAVENOUS INSULIN TREATMENT
K1002	CRANIAL ELECTROTHERAPY STIMULATION

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wound_biologic_and_misc_codesHCPCSNot Covered

M0076	Prolotherapy
M0240	Casiri and imdev repeat
M0241	Casiri and imdev repeat hm
M0243	Casirivi and imdevi inj
M0244	Casirivi and imdevi inj hm
M0245	bamlan and etesev infusion
M0246	Bamlan and etesev infus home
P9020	PLAELET RICH PLASMA UNIT
Q0240	Casirivi and imdevi 600mg
Q0243	casirivimab and imdevimab

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1/2

Listed CPT/HCPCS and S-codes in this document partHCPCSExperimental

Q4258	Celera per sq cm
Q4259	Celera per sq cm (entry)
Q4260	Signature apatch, per sq cm
Q4261	Tag, per square centimeter
Q4262	Dual layer impax, per sq cm
Q4263	Surgraft tl, per sq cm
Q4264	Cocoon membrane, per sq cm
Q4265	Neostim tl per sq cm
Q4266	Neostim per sq cm
Q4267	Neostim dl per sq cm

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Plan addendum J-/E- codesHCPCS

E1700	JAW MOTION REHAB SYSTEM
E1701	REPLACEMENT CUSHIONS FOR JAW MOTION
E1702	REPL MEASR SCALES JAW MOTION
J7604	ACETYLCYSTEINE COMP UNIT
J7607	LEVALBUTEROL COMP CON
J7609	ALBUTEROL COMP UNIT
J7610	ALBUTEROL COMP CON
J7615	LEVALBUTEROL COMP UNIT
J7622	BECLOMETHASOME INHALATION SOLUTION
J7624	BETAMETHASOME INHALATION SOLUTION

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Clinical review requirement — Listed codes are denied as non‑reimbursable and do not require clinical review

Processing stanceCodes explicitly listed in this policy are denied as non‑reimbursable and do not require clinical review when submitted on a claim.

Code sets coveredIncludes CPT Category I, HCPCS and CPT Category III (temporary) codes.

Provider expectationClaims submitted with listed codes will be denied without further clinical review per the Coverage Statement.

Most recent effective date observed

Most recent effective‑date codeA4560 — EFFECTIVE DATE = 01/15/2024

Associated descriptionA4560 DESCRIPTION = Nmes disposable

Policy effective date contextThis code appears in the reimbursement list with the most recent effective date observed in the excerpt.

Code effective date changes — update history

Summary of update historyMultiple update entries record additions and end‑dating of CPT/HCPCS codes with various effective dates (examples: added codes effective 01/15/2024, 02/01/2024, 10/01/2023; end‑dated codes 06/30/2023, 12/31/2022).

Recent additions09/27/2023 entry: Added HCPCS codes effective 01/15/2024 and 02/01/2024; added HCPCS codes effective 10/01/2023.

End‑dating activity08/07/2023 and 12/20/2022 entries: End‑dated codes on 06/30/2023 and 12/31/2022 respectively; multiple end‑date adjustments noted across update history.

Provider Expectations and Billing Guidance

Documentation Required

Provider documentation and claims coding expectations

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 per industry-standard coding guidelines (e.g., UB editor, AMA CPT®, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI policy/manual edits). Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit any additional documentation.

Submit claims using valid HIPAA code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.).
Follow industry coding guidance (AMA CPT®, CPT Assistant, UB, CMS NCCI/CCI edits).
Retain and supply clinical documentation upon request to support medical necessity and coding.

Denial Risk

Non‑reimbursable codes — denial without clinical review

The following CPT Category I, HCPCS, and CPT Category III codes are identified in this policy as non‑reimbursable (denied without clinical review) when submitted on a claim. Providers should not expect reimbursement for these codes and should not submit them as payable services.

These codes are denied as non‑reimbursable and do not require clinical review.
Providers should remove or correct non‑reimbursable codes prior to claim submission to avoid denial.

Note

Code listing (excerpt)

Excerpt (examples) of HCPCS / CPT codes listed in the policy reimbursement sections. This is not a comprehensive list; refer to the full reimbursement code listing in the policy for all codes and effective/end dates.

0435T — PRGRMG EVAL NPGS APNEA 1 SES (eff 04/15/2022)
0436T — PRGRMG EVAL NPGS APNEA STUDY (eff 04/15/2022)
0444T — INITIAL PLACEMENT OF A DRUG ELUTING (eff 12/01/2020; end-dated 12/31/2022)
0445T — SBSQT PLMT DRUG ELUT OC INS (eff 12/01/2020; end-dated 12/31/2022)
0464T — VISUAL EP TEST FOR GLAUCOMA (eff 12/01/2020)

Billing Rule

Reimbursement code list (partial)

Partial reimbursement code list (examples) included in the policy's reimbursement information. Providers should reference the official code groups and effective/end dates when determining billing and reimbursement applicability.

G0255 — CURRENT PERCEP THRESHOLD TST (eff 09/01/2020)
G0281 — ELECT STIM UNATTEND FOR PRESS (eff 09/01/2020)
G0282 — ELECT STIM WOUND CARE NOT PD (eff 09/01/2020)
G0295 — ELECTROMAGNETIC THERAPY ONC (eff 09/01/2020)
G0329 — ELECTROMAGNTIC TX FOR ULCERS (eff 09/01/2020)
G0428 — COLLAGEN MENISCUS IMPLANT PROCEDURE (eff 12/01/2020)
G0460 — AUTOLOGOUS PRP FOR ULCERS (eff 12/01/2020)
G0465 — AUTOLOG PRP DIAB WOUND ULCER (eff 04/15/2022)
G9147 — OUTPATIENT INTRAVENOUS INSULIN TREATMENT (eff 12/01/2020)
K1002 — CRANIAL ELECTROTHERAPY STIMULATION (eff 12/01/2020)

Note

Reference update history for code effective dates

Policy Update History tracks addition and end-dating of CPT/HCPCS codes and their effective dates. Providers MUST reference the update history and the policy's reimbursement sections to confirm current applicability of codes before billing.

09/27/2023 — Added HCPCS codes effective 01/15/2024 and 02/01/2024; added HCPCS codes effective 10/01/2023.
08/07/2023 — End-dated codes 06/30/2023; added HCPCS codes effective 12/01/2023.
05/26/2023 — Added new CPT/HCPCS codes effective 07/01/2023 (revised to 09/01/2023).
12/20/2022 — End-dated codes 12/31/2022; added new CPT/HCPCS codes effective 01/01/2023 and 04/01/2023.
03/29/2022 and 04/22/2022 — Added HCPCS/CPT codes effective 04/01/2022 and 08/01/2022 respectively; 01/10/2022 — Added CPT/HCPCS codes effective 04/15/2022.

Terms and Reimbursement Information

EIU — Experimental/Investigational/Unproven defined

Definition (EIU)Experimental/Investigational/Unproven (EIU): services determined in the Coverage Statement to be experimental, investigational or unproven and denied as non‑reimbursable when submitted on a claim.

ScopeApplies to procedures or categories of codes identified in the policy's reimbursement list.

Resulting actionDesignated EIU services are processed as denials without clinical review per this policy.

Reimbursement Information entries — code, description, effective date, end date

Entry formatReimbursement Information entries list code, description, EFFECTIVE DATE, and END DATE (when present).

Example entry0435T — PRGRMG EVAL NPGS APNEA 1 SES. — EFFECTIVE DATE = 04/15/2022

Example entryA2019 — Kerecis marigen shld sq cm — EFFECTIVE DATE = 09/01/2023

Reimbursement Information — selected codes with descriptions and effective dates

Sample codes listedG0255 — CURRENT PERCEP THRESHOLD TST (EFFECTIVE DATE = 09/01/2020)

Sample codes listedG0465 — AUTOLOG PRP DIAB WOUND ULCER (EFFECTIVE DATE = 04/15/2022)

Sample codes listed0444T — INITIAL PLACEMENT OF A DRUG ELUTING (EFFECTIVE DATE = 12/01/2020; END DATE = 12/31/2022)

BIT429 flag (plan addendum) — 'X in column indicates BIT429 ON for that plan'

BIT429 notation'X' in a column indicates BIT429 is ON for that plan (plan‑specific addendum flag).

Applicability exampleE1700 (JAW MOTION REHAB SYSTEM) — NM = X (BIT429 ON for New Mexico).

PurposeDenotes that codes listed in the Plan Addendum are effective in BIT429 for specified states/plans.

Coding systems — CPT and HCPCS notes

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

HCPCS definitionHCPCS stands for the Healthcare Common Procedure Coding System.

OpenPayer

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

Coverage Statement and Non‑Reimbursable Codes

Code Examples and Effective Dates

Provider Expectations and Billing Guidance

Terms and Reimbursement Information