CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP028

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

Lists specific procedure, CPT, and HCPCS codes that Blue Cross Blue Shield of Oklahoma has determined to be experimental, investigational, and/or unproven and therefore non-reimbursable under member plan documents; applies to providers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeNo material change

Effective DateOctober 1, 2024

Next Review DateN/A

Key ActionDo not submit claims for codes listed as experimental/investigational/unproven; claims for those codes will be denied as non-reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50+non-reimbursable codes

3.0policy version

Jun 21, 2024approval date

OKOK BIT429 flag

multipleentries with dates

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 Services and Code-Level Applicability

Non-Reimbursable Services List

Covered when ALL of the following are met:

The listed services (procedure codes or categories of codes) are explicitly determined to be experimental, investigational, or unproven and are not reimbursable under the member's plan documents.

Codes included may be CPT Category I, HCPCS, and CPT Category III (temporary) codes; services billed using these codes will be denied as non-reimbursable when submitted on a claim.

These non-reimbursable determinations do not require clinical review to determine coverage when the codes are submitted on a claim.

The list may not be all-inclusive; reimbursement denials are based on the member's plan documents in effect.

Code list fragment

Partial excerpt of temporary CPT/HCPCS codes and descriptions present in the policy segment (effective and end dates included where shown):

Examples

0275T — PERQ LAMOT/LAM LUMBAR. EFFECTIVE DATE = 01/01/2023.
0278T — TEMPR. EFFECTIVE DATE = 12/01/2020.
0330T — TEAR FILM IMG UNI/BI W/I&R. EFFECTIVE DATE = 09/01/2020.
0347T — INS BONE DEVICE FOR RSA. EFFECTIVE DATE = 09/01/2020.
0424T — INSJ/RPLC NSTIM APNEA COMPL. EFFECTIVE DATE = 04/15/2022.
0425T — INSJ/RPLC NSTIM APNEA SEN LD. EFFECTIVE DATE = 04/15/2022. END DATE = 12/31/2023.

Additional entries

Code listing (no criteria)

Enumerated HCPCS/CPT and related code entries (descriptions and effective/end dates as listed). No clinical coverage criteria provided in these entries:

ANY of the following

C9364 — PORCINE IMPLANT PERMACOL. EFFECTIVE DATE = 12/01/2020.
C9757 — Spine/lumbar disk surgery. EFFECTIVE DATE = 08/01/2022.
C9771 — Nsl/sins cryo post nasal tis. EFFECTIVE DATE = 07/15/2021. END DATE = 12/31/2023.
Q4222 — Progenamatrix, per sq cm. EFFECTIVE DATE = 05/15/2021.
Q4224 — Human health factor 10 amniotic patch (hhf10-p), per square centimeter. EFFECTIVE DATE = 04/01/2022.

Plan applicability flags

Plan addendum indicates per-code plan applicability via BIT429 columns (an 'X' indicates BIT429 is ON for that plan/state):

ANY of the following

E1700 — JAW MOTION REHAB SYSTEM. IL = X; MT = X; NM = X; OK = X; TX = .; END DATE = 06/30/2024.
E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. IL = X; MT = X; NM = X; OK = X; TX = .; END DATE = 06/30/2024.
E1702 — REPL MEASR SCALES JAW MOTION. IL = X; MT = X; NM = X; OK = X; TX = .; END DATE = 06/30/2024.

Presence of 'X' under the OK column indicates the listed code is enabled in BIT429 for the Oklahoma plan as shown in the addendum entries.

BIT429 plan addendum entries

BIT429 activation table entries for multiple HCPCS/J codes (X indicates BIT429 ON for that plan/state):

Selected BIT429-flagged J- and related codes

J7604 — ACETYLCYSTEINE COMP UNIT. IL = X; NM = X; OK = X; TX = X.
J7607 — LEVALBUTEROL COMP CON. IL = X; NM = X; OK = X; TX = X.
J7609 — ALBUTEROL COMP UNIT. IL = X; NM = X; OK = X; TX = X.
J7622 — BECLOMETHASOME INHALATION SOLUTION. IL = X; NM = X; OK = X; TX = X.
J7634 — BUDESONIDE INHALATION SOLUTION CO. (multiple plan columns show X where indicated).

Code Tables and Effective/End Dates

Examples from the enumerated non-reimbursable codesCPTExperimental

17340	CRYOTHERAPY OF SKIN
20560	NDL INSJ W O NJX 1 OR 2 MUSC
20985	CPTR-ASST DIR MS PX

Additional Category III / temporary codes listedmixedExperimental

0052U	LPOPRTN BLD W/5 MAJ CLASSES
0101T	EXTRACORP SHOCKWV TX HI ENRG
0347T	INS BONE DEVICE FOR RSA

A-codes (wound matrices and related supplies)HCPCS

A2001	Innovamatrix ac, per sq cm
A2010	Apis, per square centimeter
A2026	Restrata minimatrix, 5 mg

C-codes (drug/device injections and biologic matrices)HCPCS

C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg
C9354	ACELLULAR PERICARDIAL TISSUE MATRIX
C9771	Nsl/sins cryo post nasal tis

T-codes (temporary CPT entries)CPT

0275T	PERQ LAMOT/LAM LUMBAR
0330T	TEAR FILM IMG UNI/BI W/I&R
0424T	INSJ/RPLC NSTIM APNEA COMPL

E-codes (DME / device systems)HCPCS

E0732	Ces system
E0221	INFRARED HEATING PAD SYSTEM

Selected C-codesmixed

C9364	PORCINE IMPLANT PERMACOL
C9757	Spine/lumbar disk surgery
C9768	Endo us-guide hep porto grad

Selected E-codesmixed

E0221	INFRARED HEATING PAD SYSTEM
E0231	WOUND WARMING DEVICE
E0487	ELECTRONIC SPIROMETER

Selected G- and P-codesmixed

G0428	COLLAGEN MENISCUS IMPLANT PROCEDURE
G0460	AUTOLOGOUS PRP FOR ULCERS
P9020	PLAELET RICH PLASMA UNIT

Selected K-codesmixed

K1002	CRANIAL ELECTROTHERAPY STIMULATION
K1009	Speech volume modulation sys
K1036	Supplies for ultra diatherm

Selected Q-codes (biologic/wound matrices)mixed

Q4103	Oasis burn matrix
Q4110	Primatrix
Q4112	Cymetra injectable

Sample Q-codes for amniotic/cord/graft productsHCPCS

Q4216	ARTACENT CORD, per square centimeter
Q4217	WOUNDFIX, BIOWOUND, WOUNDFIX PLUS
Q4218	SURGICORD, per square centimeter

Later-year Q-codes (2023-2024 additions)HCPCS

Q4261	Tag, per square centimeter
Q4279	Vendaje ac, per sq cm (eff 07/01/2024)
Q4292	Lamellas, per sq cm (eff 07/01/2024)

Sample S-codes present in listHCPCS

S2117	ARTHROEREISIS SUBTALAR
S2300	ARTHROSCOPY SHOULDER SURGI
S3650	SALIVA TEST HORMONE LEVEL DURING

BIT429-flagged codesHCPCS

E1701	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
J7627	BUDESONIDE COMP UNIT

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End date presence

Presence of explicit END DATESome codes in the reimbursement lists include an explicit END DATE (for example multiple T‑codes and other entries show END DATE = 12/31/2023 or other end dates)

Missing end date on many entriesMany code entries show an empty END DATE field (END DATE = .), indicating no end date is listed in the document for those codes

Examples with end datesT-code series 0425T–0436T and 0425T–0433T group include END DATE = 12/31/2023 for multiple entries

Plan addendum end-dates

Billing, Documentation, and Plan Addendum Notes

Documentation Required

Provider billing and documentation responsibilities / claim review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and code combinations. Claims should be coded according to industry-standard coding guidelines (including but not limited to Uniform Billing Editor; AMA CPT and CPT Assistant; HCPCS; ICD-10-CM/PCS; NDCs; DRG; CMS NCCI policy manual; CCI table edits). Claims are subject to code-edit protocols and claim review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should supply additional documentation to support the claim.

Use valid HIPAA-approved code sets and industry coding guidelines when submitting claims.
Claims are subject to code-edit protocols and may be reviewed for coverage and coding accuracy.
Provide additional documentation upon request.

Note

No clinical review required for listed EIU services

Listed services in this policy are designated as non-reimbursable (experimental/investigational/unproven) and do not require clinical review when submitted on a claim — they will be denied as non-reimbursable based on the member's plan documents.

Terms and Flags Used in This Policy

Experimental/Investigational/Unproven (EIU)

Definition of EIUServices, procedures, or technologies explicitly determined in the Coverage Statement of the Medical Policy to be experimental, investigational, or unproven and therefore non-reimbursable; codes listed will be denied as non-reimbursable when submitted.

Scope of listIncludes CPT Category I, HCPCS and CPT Category III (temporary) codes that are designated EIU

Clinical review not requiredListed services do not require clinical review to determine coverage when submitted on a claim because they are pre-designated as non-reimbursable.

Reimbursement Information (definition)

Reimbursement Information field definitionEntries list the code, a short description, EFFECTIVE DATE and END DATE when provided (END DATE may be blank)

Code example with effective date

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeNo material change

Effective DateOctober 1, 2024

Next Review DateN/A

Key ActionDo not submit claims for codes listed as experimental/investigational/unproven; claims for those codes will be denied as non-reimbursable.

SourceLink

On This Page

0335T — INSERTION OF SINUS TARSI IMPLANT. EFFECTIVE DATE = 12/01/2020.

0338T — TRNSCTH RENAL SYMP DENRV UNL. EFFECTIVE DATE = 09/01/2020.

0358T — BIA WHOLE BODY. EFFECTIVE DATE = 12/01/2020.

0369U — IADNA GI PTHGN 31 ORG&21 ARG. EFFECTIVE DATE = 05/15/2024.

Note: Effective and end dates are shown where provided in the reimbursement entries; some entries list END DATE (for example multiple 12/31/2023 entries).

Q4226 — Myown harv prep proc sq cm. EFFECTIVE DATE = 10/01/2024.

These entries are provided as reimbursement information only; the policy section enumerates codes and dates but does not include additional prior authorization or documentation instructions in these chunks.

J7641 — FLUNISOLIDE, INHALATION SOLUTION AD. multiple plan columns show X where indicated.

For the listed J- and other codes in the addendum, the OK column shows 'X' for many entries indicating BIT429 is ON for Oklahoma for those codes per the plan addendum.

Some plan addendum entries (e.g., E1701/E1702) include an explicit END DATE = 06/30/2024

Actionable noteWhen submitting claims, verify the code-specific END DATE in the policy list because some codes are time-limited and will be denied after the listed end date

EFFECTIVE DATE presence

EFFECTIVE DATE present for most entriesMost reimbursement entries list an EFFECTIVE DATE (e.g., 0275T EFFECTIVE DATE = 01/01/2023; C9364 EFFECTIVE DATE = 12/01/2020)

Some entries omit END DATEWhile EFFECTIVE DATE is commonly present, many entries show END DATE = . (no end date listed)

Effective dates span multiple yearsEffective dates in the lists range across 2020–2024 for various CPT/HCPCS entries

Use EFFECTIVE DATE for claim timingProviders should use the EFFECTIVE DATE to determine whether a code was in effect at the time of service

Code effective date updates (2020–2024)

Updates recorded 2020–2024Policy update history documents multiple additions and end-dates for CPT/HCPCS codes from 2020 through 2024 (see 06/21/2024, 03/20/2024, 02/07/2024 entries)

Specific additions and end-datesHistory notes additions effective 07/01/2023, 10/01/2023, 01/15/2024, 02/01/2024 and end-dated codes (e.g., codes end-dated 12/31/2023; 03/31/2024; 06/30/2023)

Removed older end-dated codesThe update history documents removal of codes that were end-dated in 2020 and 2021

Action for billing teamsReview the Policy Update History when reconciling code lists to ensure you use the currently effective code set and respect recent end-dates

Includes CPT Category I, CPT Category III (temporary) and HCPCS codes that are identified as non-reimbursable.
This list may not be all inclusive; denials will be based on plan documents.

Billing Rule

Reimbursement code listings (partial)

Partial list of temporary CPT/HCPCS codes and descriptions identified for non-reimbursement (effective dates shown when available).

0275T — PERQ LAMOT/LAM LUMBAR. Effective 01/01/2023.
0278T — TEMPR. Effective 12/01/2020.
0330T — TEAR FILM IMG UNI/BI W/I&R. Effective 09/01/2020.
0322U — NEURO ASD MEAS 14 ACYL CARN. Effective 02/01/2024.
0335T — INSERTION OF SINUS TARSI IMPLANT. Effective 12/01/2020.
0338T — TRNSCTH RENAL SYMP DENRV UNL. Effective 09/01/2020.
0339T — TRNSCTH RENAL SYMP DENRV BIL. Effective 09/01/2020.
C9364 — PORCINE IMPLANT PERMACOL. Effective 12/01/2020.
C9757 — Spine/lumbar disk surgery. Effective 08/01/2022.
C9768 — Endo us-guide hep porto grad. Effective 03/01/2021.
C9771 — Nsl/sins cryo post nasal tis. Effective 07/15/2021. End Date 12/31/2023.
C9772 — REVASC LITHOTRIP TIBI/PERONE. Effective 08/15/2021.
C9773 — REVASC LITHOTR-STENT TIB/PER. Effective 08/15/2021.
C9774 — REVASC LITHOTR-ATHER TIB/PER. Effective 08/15/2021.
C9775 — REVASC LITH-STEN-ATH TIB/PER. Effective 08/15/2021.
C9777 — ESOPHAG MUCOSAL INTEG ADD-ON. Effective 08/15/2021.
C9784 — Endo sleeve gastro w/tube. Effective 12/01/2023.

Billing Rule

Reimbursement code list (no auth instructions)

Additional reimbursement code entries identified as non-reimbursable (no prior authorization instructions included).

C9784 — Endo sleeve gastro w/tube. (Effective 12/01/2023)
(List continues in source — entries include device and procedure HCPCS codes with effective/end dates where available)

Note

Plan addendum code flags (BIT429)

Plan addendum code flags (BIT429) indicate which codes have BIT429 enabled for each state. An 'X' under OK indicates the code is enabled for the Oklahoma plan.

E1700 — JAW MOTION REHAB SYSTEM. OK = X. End Date 06/30/2024.
E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. OK = X. End Date 06/30/2024.
E1702 — REPL MEASR SCALES JAW MOTION. OK = X. End Date 06/30/2024.
Multiple J‑codes (e.g., J7604, J7607, J7609, J7610, J7615, J7622, J7624, J7627, J7628, J7629, J7632) show BIT429 = X for OK where indicated in the plan addendum.

Note

Plan addendum entries for E1701/E1702

Specific plan addendum entries for E1701 and E1702 show BIT429 = X for IL, MT, NM, and OK, with end dates noted.

E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. IL = X; MT = X; NM = X; OK = X; End Date 06/30/2024.
E1702 — REPL MEASR SCALES JAW MOTION. IL = X; MT = X; NM = X; OK = X; End Date 06/30/2024.

Note

J‑code BIT429 activations

J‑code BIT429 activations from the plan addendum (OK column marked 'X' indicates activation for Oklahoma).

J7604 — ACETYLCYSTEINE COMP UNIT. OK = X.
J7607 — LEVALBUTEROL COMP CON. OK = X.
J7609 — ALBUTEROL COMP UNIT. OK = X.
J7610 — ALBUTEROL COMP CON. OK = X.
J7615 — LEVALBUTEROL COMP UNIT. OK = X.
J7622 — BECLOMETHASOME INHALATION SOLUTION. OK = X.
J7624 — BETAMETHASOME INHALATION SOLUTION. OK = X.
J7627 — BUDESONIDE COMP UNIT. OK = X.
J7628 — BITOLTEROL MESYLATE, INHALATION SOL. OK = X.
J7629 — BITOLTEROL MESYLATE INHALATION SOL. OK = X.
J7632 — CROMOLYN SODIUM COMP UNIT. OK = X.

0275T — PERQ LAMOT/LAM LUMBAR — EFFECTIVE DATE = 01/01/2023

Code example with blank end dateC9364 — PORCINE IMPLANT PERMACOL — EFFECTIVE DATE = 12/01/2020 — END DATE = .

Time-limited code example0425T — INSJ/RPLC NSTIM APNEA SEN LD — EFFECTIVE DATE = 04/15/2022 — END DATE = 12/31/2023

Reimbursement Information (entry format)

Entries include code, description, EFFECTIVE DATE and END DATE when providedMost listed reimbursement rows follow the pattern: CODE, DESCRIPTION, EFFECTIVE DATE = mm/dd/yyyy, END DATE = mm/dd/yyyy or blank

Example: coded entries with end dates0425T–0436T group: EFFECTIVE DATE = 04/15/2022; END DATE = 12/31/2023 for many entries

Example: coded entries without end datesC9364 (PORCINE IMPLANT PERMACOL) shows EFFECTIVE DATE = 12/01/2020 and END DATE = . (no end date listed)

Practical implicationVerify both EFFECTIVE and END DATES in the reimbursement listing to determine whether a code is currently non-reimbursable at time of service

HCPCS / CPT

HCPCS definitionHCPCS = Healthcare Common Procedure Coding System

CPT definitionCPT = Current Procedural Terminology (American Medical Association)

BIT429 activation flag

Meaning of 'X' in BIT429 columnAn 'X' in the column indicates BIT429 is ON for that plan/state for the listed code

Plan-level applicabilityBIT429 indicates per-code activation for specific plans/states (example: E1701 and E1702 show IL= X, MT= X, NM= X, OK= X)

End-date noted in addendumSome BIT429 plan addendum entries include an END DATE (e.g., E1701/E1702 END DATE = 06/30/2024)

Action for billingUse the BIT429 flag in the plan addendum to determine whether a given code is enabled for a member's state/plan before submitting a claim