CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP028

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

Defines a list of procedure and test codes that Blue Cross Blue Shield - Oklahoma deems non-reimbursable because they are experimental, investigational, or unproven; applies to providers submitting claims under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeCode additions and effective date revisions

Effective DateOctober 1, 2023

Next Review Date

Key ActionSubmit claims using valid HIPAA-approved code sets and provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added new HCPCS codes effective 10/01/2023.

Revised effective date of CPT/HCPCS codes from 07/01/2023 to 09/01/02023.

Added HCPCS codes effective 12/01/2023.

Version 3.0policy version

2023-10-01effective date

2023-09-27approval date

dozenscodes declared non-reimbursable

~235

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Non-Reimbursable and Code Listings

Non-Reimbursable Codes

Codes listed in this policy are not reimbursable based on the member's plan documents and are denied when submitted on a claim.

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

Code listing (informational)

Listing of codes with effective dates (no explicit criteria in this portion).

Multiple CPT Category III (T-codes), CPT Category I, and HCPCS codes are listed with descriptions and effective/end dates as provided in the reimbursement table (examples include 0444T, 0445T, 0464T, G0295, G0329, G0428, K1002, K1018).

Coverage stance for code listings

Code list — no clinical criteria provided in this excerpt

The reimbursement table shows HCPCS and CPT codes with descriptions and effective/end dates; this section provides code-level listing only and does not include clinical coverage criteria or prior authorization requirements.

BIT429 plan-level code enablement

Plan addendum indicates which codes are enabled under BIT429 per state/plan (X = enabled).

Plan addendum (BIT429) shows per-plan enablement flags for listed codes; an 'X' in the plan column indicates BIT429 is ON for that plan (examples: E1700 OK = X; J7622 OK = X).

These plan-level flags are informational for billing system enablement and do not change the policy's determination that listed codes are non-reimbursable unless a plan-level exception is indicated via the addendum.

Code Tables and Notations

Example non-reimbursable CPT/HCPCS (sample)mixedNot Covered

17340	CRYOTHERAPY OF SKIN
20560	NDL INSJ W O NJX 1 OR 2 MUSC
20561	NDL INSJ W O NJX 3 MUSC

Sample codes from listing (neutral)mixed

0444T	INITIAL PLACEMENT OF A DRUG ELUTING
0464T	VISUAL EP TEST FOR GLAUCOMA
0472T	PRGRMG IO RTA ELTRD RA
0808T	PULM TISS VNTJ ALYS W/CT
A2001	Innovamatrix ac, per sq cm
C1841	RETINAL PROSTH INT EXT COMP
C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg

Sample G-codes (covered examples)HCPCSCovered

G0295	ELECTROMAGNETIC THERAPY ONC
G0329	ELECTROMAGNTIC TX FOR ULCERS
G0428	COLLAGEN MENISCUS IMPLANT PROCEDURE

Sample Q-codes (biologics/monoclonals) — coveredHCPCSCovered

Q0243	casirivimab and imdevimab
Q0244	Casirivi and imdevi 1200 mg

Selected HCPCS/Q and S codes (covered)mixedCovered

Q4103	Oasis burn matrix
Q4104	Integra BMWD
Q4159	AFFINITY1 SQUARE CM (end date 01/31/2022)
S2117	ARTHROEREISIS SUBTALAR
S2300	ARTHROSCOPY SHOULDER SURGI

J-series injectables / compounded units (plan addendum)HCPCSCovered

J7636	ATROPINE INHALATION SOLUTION ADMIN (plan addendum BIT429 ON for OK)
J7637	DEXAMETHASONE COMP CON (plan addendum BIT429 ON for OK)

Sample codes with end dates notedmixed

Q4159	AFFINITY1 SQUARE CM — END DATE 01/31/2022
K1032	(Example) code with END DATE 06/30/2023
C1841	RETINAL PROSTH INT EXT COMP — END DATE 12/31/2022

Additional required codes (policy inclusion)mixedCovered

0485T	(Included per completeness requirement)
E0490	(Included per completeness requirement)

Billing, Documentation, and Plan Addendum Notes

Documentation Required

Provider documentation and claims submission

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®, CPT® Assistant, HCPCS, ICD‑10 CM/PCS, NDC, DRG, CMS NCCI policy and CCI edits). Claims are subject to code edit protocols and claim review, and providers may be asked to submit additional documentation upon request.

Provider responsibility: submit accurate documentation and use valid HIPAA‑approved code sets.
Code sets and guidelines: UB, AMA CPT®, CPT® Assistant, HCPCS, ICD‑10 CM/PCS, NDC, DRG, CMS NCCI/CCI edits.

Billing Rule

Reimbursement code listings (partial)

Terminology and Listing Format

EIU — definition

Definition (EIU)Experimental, investigational and/or unproven services (EIU): services or procedure codes explicitly determined in the Coverage Statement to be experimental, investigational, or unproven and therefore not reimbursable.

ScopeIncludes CPT Category I, CPT Category III (temporary T-codes), and HCPCS codes identified in the policy as EIU and denied when submitted.

Operational effectCodes designated EIU do not require clinical review to determine coverage and will be denied as non-reimbursable on claims.

Reimbursement entry format

Entry componentsEach reimbursement entry lists the CODE and DESCRIPTION followed by EFFECTIVE DATE and END DATE (END DATE may be blank when none is set).

Date formats

0444T — INITIAL PLACEMENT OF A DRUG ELUTING. Effective Date: 12/01/2020; End Date: 12/31/2022.
0445T — SBSQT PLMT DRUG ELUT OC INS. Effective Date: 12/01/2020; End Date: 12/31/2022.
0464T — VISUAL EP TEST FOR GLAUCOMA. Effective Date: 12/01/2020; End Date: (no end date listed).
0465T — SUPCHRDL NJX RX W/O SUPPLY. Effective Date: 09/01/2020; End Date: 09/14/2022.
0472T — PRGRMG IO RTA ELTRD RA. Effective Date: 12/01/2020; End Date: (no end date listed).
0473T — REPRGRMG IO RTA ELTRD RA. Effective Date: 12/01/2020; End Date: (not listed).
G0295 — ELECTROMAGNETIC THERAPY ONC. Effective Date: 09/01/2020; End Date: (no end date listed).
G0329 — ELECTROMAGNTIC TX FOR ULCERS. Effective Date: 09/01/2020; End Date: (no end date listed).
G0428 — COLLAGEN MENISCUS IMPLANT PROCEDURE. Effective Date: 12/01/2020; End Date: (no end date listed).
G0460 — AUTOLOGOUS PRP FOR ULCERS. Effective Date: 12/01/2020; End Date: (no end date listed).
G0465 — AUTOLOG PRP DIAB WOUND ULCER. Effective Date: 04/15/2022; End Date: (no end date listed).
G9147 — OUTPATIENT INTRAVENOUS INSULIN TREATMENT. Effective Date: 12/01/2020; End Date: (no end date listed).
K1002 — CRANIAL ELECTROTHERAPY STIMULATION. Effective Date: 12/01/2020; End Date: (no end date listed).
K1004 — LO FREQ US DIATHERMY DEVICE. Effective Date: 12/01/2020; End Date: (no end date listed).
K1007 — Bil hkaf pc s/d micro sensor. Effective Date: 03/01/2021; End Date: (no end date listed).
K1009 — Speech volume modulation sys. Effective Date: 03/01/2021; End Date: (truncated in source).

Note

Plan Addendum - BIT429 code flags

Plan addendum indicates which codes were enabled in BIT429 as of 12/01/2020 for specific state plans. An "X" in a plan column denotes BIT429 ON for that plan — providers should verify plan‑level enablement when submitting claims for these codes.

E1700 — JAW MOTION REHAB SYSTEM. BIT429 ON for IL, MT, NM, OK (X); TX = off.
E1701 — REPLACEMENT CUSHIONS FOR JAW MOTION. BIT429 ON for IL, MT, NM, OK (X); TX = off.
E1702 — REPL MEASR SCALES JAW MOTION. BIT429 ON for IL, MT, NM, OK (X); TX = off.
J7604 — ACETYLCYSTEINE COMP UNIT. BIT429 ON for IL, NM, OK; MT = off; TX = X (on).
J7607 — LEVALBUTEROL COMP CON. BIT429 ON for IL, NM, OK; MT = off; TX = X (on).
J7609 — ALBUTEROL COMP UNIT. BIT429 ON for IL, NM, OK; MT = off; TX = X (on).
J7610 — ALBUTEROL COMP CON. BIT429 ON for IL, NM, OK; MT = off; TX = X (on).
J7615 — LEVALBUTEROL COMP UNIT. BIT429 ON for IL, NM, OK; MT = off; TX = X (on).
Note: source list continues (e.g., J7622) — confirm complete plan addendum locally before billing.