CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP028

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

Defines procedure, CPT/HCPCS and Category III codes that BCBSOK deems experimental, investigational or unproven and therefore non‑reimbursable when billed; applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeNo material changes

Effective Date12/01/2023

Next Review Date

Key ActionSubmit claims using valid HIPAA‑approved code sets and expect listed services to be denied as non‑reimbursable when billed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12/01/2023policy effective date

Version 3.0policy version

100+codes listed (approx)

Denial without clinical reviewdenial behavior

~240code entries (approx)

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 Coverage Position

Non‑reimbursable stance

Codes listed in this policy are identified as not reimbursable because they are determined to be experimental, investigational, or unproven and will be denied when submitted on a claim.

Codes included in this policy (CPT Category I, CPT Category III, and HCPCS) are explicitly determined to be experimental, investigational, or unproven.

Services represented by the listed procedure codes do not require clinical review to determine coverage and will be denied when submitted on a claim.

The list of non-reimbursable codes is not all-inclusive; denials are based on the member's plan documents.

Code listing (no coverage criteria provided in these chunks)

Code listing with dates; no coverage rules in these chunks.

Reimbursement entries list codes with descriptions and effective/end dates (examples shown: 0444T, 0445T, 0464T, 0465T, 0472T, A9291, C1052, C1823).

Effective and end dates are provided where available for each code entry; some entries include explicit end dates.

Code listing (no criteria)

Code list; no explicit coverage criteria in this excerpt.

This section enumerates multiple HCPCS/G/K/Q and other codes with short descriptions and effective dates (examples: G0281, G0282, G0295, G0329, G0428, G0460, K1002, K1004).

Entries serve as the policy's listing of services deemed experimental/investigational/unproven and include date fields for reference.

Code list and plan applicability

Codes and descriptions provided in this section are part of the policy's list of experimental/unproven services and include plan-specific applicability flags.

Multiple Q- and S- HCPCS/CPT entries and product codes are listed with effective dates (examples: Q4257–Q4272, Q4273–Q4284, Q4285–Q4286, S2117–S905), used to identify non-reimbursable items.

Plan addendum (BIT429) flags indicate plan-specific applicability for certain J- and E- codes; the addendum shows which plans have BIT429 ON (marked X) for each code.

The plan addendum entries (e.g., E1700–E1702, J7604, J7607, J7609, J7610, J7615, J7622, etc.) list per-plan columns (IL, MT, NM, OK, TX, etc.) with 'X' marking BIT429 ON for that plan.

Lists of Codes and Coding Details

Examples of non-reimbursable procedure codesmixedNot Covered

17340	CRYOTHERAPY OF SKIN
20560	NDL INSJ W O NJX 1 OR 2 MUSC
22526	IDET SINGLE LEVEL
22867	INSJ STABLJ DEV W/DCMPRN
28890	HI ENRGY ESWT PLANTAR FASCIA
30468	RPR NSL VLV COLLAPSE W/IMPLT

Examples of non-reimbursable lab and GI codesmixedNot Covered

82523	COLLAGEN CROSSLINKS
83695	ASSAY OF LIPOPROTEIN(A)
86328	IA NFCT AB SARSCOV2 COVID19
86413	SARS-COV-2 ANTB QUANTITATIVE
91111	ESOPHAGEAL CAPSULE ENDOSCOPY
91113	GI TRC IMG INTRAL COLON I&R

Selected Category III / temporary codes listedmixedNot Covered

0052U	LPOPRTN BLD W/5 MAJ CLASSES
0106U	GASTRIC EMPTYING SERIAL COLLECTION
0198T	OCULAR BLOOD FLOW MEASURE
0219T	PLACEMENT OF A POSTERIOR INTRAFACET

Sample codes and descriptions from listingmixed

A9291	Prescription digital behavioral therapy, fda cleared, per course of treatment
C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere), 1 mg
E0490	Power source/control electronics unit for oral device/appliance for neuro musc elec stim tongue muscle

reimbursement_codesmixed

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.
K1004	LO FREQ US DIATHERMY DEVICE.

1–10 of 53

1/6

Listed Q- and S- HCPCS/CPT codesHCPCSExperimental

Q4257	Relese, per square centimeter
Q4258	Enverse, per square centimeter
Q4259	Celera per sq cm
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

1–10 of 39

1/4

Plan addendum J- and E-codes with per-plan flagsHCPCS

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

1–10 of 12

1/2

Effective date presence

SummaryMany code entries include an effective date; dates vary by code (examples: 0444T EFFECTIVE DATE = 12/01/2020; 0465T EFFECTIVE DATE = 09/01/2020).

ScopeEffective dates are provided for Category I, III and HCPCS codes throughout the reimbursement lists (see multiple entries).

ImplicationClaims submitted for codes should be checked against the listed effective dates to confirm the code was active for the service date.

ExamplesG0281 EFFECTIVE DATE = 09/01/2020; K1007 EFFECTIVE DATE = 03/01/2021; Q4273 EFFECTIVE DATE = 12/01/2023.

code end dates present

Provider Billing, Documentation, and Claim Handling

Documentation Required

Provider documentation and claims submission

Providers are responsible for submitting accurate documentation of services performed and must submit claims using HIPAA‑approved code sets (CPT®, HCPCS, ICD-10, NDC, UB, DRG, etc.). Claims are subject to code-edit protocols and claim review; upon request providers must supply additional documentation. Providers should code according to industry-standard guidelines (AMA, CMS NCCI/CCI, CPT Assistant).

Submit claims using valid HIPAA-approved code sets (CPT®, HCPCS, ICD-10, NDC, UB, DRG).
Claims are subject to code-edit protocols, benefit coverage terms, provider contract language, medical policies, and coding software logic.
Upon request, providers must submit additional documentation to support the claim.

Denial Risk

Non‑reimbursable denial rule

The policy identifies specific procedure codes that are non-reimbursable and will be denied when submitted; these do not require clinical review to determine coverage. The list includes CPT Category I, HCPCS, and CPT Category III codes deemed experimental, investigational, or unproven. Submissions for these codes will be denied as non-reimbursable per the member's plan documents.

Key Definitions and Governing Terms

EIU — Experimental/Investigational/Unproven services

DefinitionServices explicitly determined to be experimental, investigational and/or unproven are identified as non‑reimbursable under this policy.

Code sets includedThe list includes CPT Category I, HCPCS and CPT Category III (temporary) codes deemed experimental/ investigational/ unproven.

Denial ruleThese services do not require clinical review to determine coverage and will be denied when submitted on a claim.

ApplicabilityApplies to providers submitting claims to Blue Cross Blue Shield of Oklahoma per the policy.

Hierarchy of governing documents

Governing priorityIf a conflict arises between a CPCP and any plan document, the plan document will govern.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeNo material changes

Effective Date12/01/2023

Next Review Date

Key ActionSubmit claims using valid HIPAA‑approved code sets and expect listed services to be denied as non‑reimbursable when billed.

SourceLink

On This Page

Presence of end datesSome code entries explicitly list an end date (e.g., K1024 END DATE = 06/30/2023).

Partial coverage of end datesSeveral codes show no end date listed (END DATE = .) indicating no explicit end date provided in the table.

Operational noteEnd dates where present indicate when the code was removed from the non‑reimbursable listing; verify claim date against end date.

Example entriesK1024 END DATE = 06/30/2023; K1025 END DATE = 06/30/2023; K1031 END DATE = 06/30/2023.

BIT429 flag presence

BIT429 flag meaningColumn X in the Plan Addendum indicates BIT429 is ON for that plan.

Plan applicabilityThe OK column shows X for many codes in the addendum, indicating BIT429 ON for Blue Cross Blue Shield - Oklahoma.

Affected codesExamples include E1700, E1701, E1702 and multiple J‑codes listed with OK = X.

Operational useBIT429 flags identify plan‑specific applicability for codes listed in the Plan Addendum; check plan column X for applicability.

Non-reimbursable denials apply to listed CPT I, CPT III, and HCPCS codes determined experimental/investigational/unproven.
These codes will be denied at claim adjudication without clinical review for coverage.
The list of non-reimbursable codes is not all-inclusive; verify member plan documents for final coverage determinations.

Billing Rule

Plan addendum / BIT429 flags

Plan addendum/bit-flag summary: Certain J-/E-/other HCPCS codes are marked with BIT429 on a per-plan basis. An 'X' in the plan column indicates BIT429 is ON for that plan (plan-specific applicability). For Oklahoma (OK) many listed codes show BIT429 = X — providers should refer to the plan addendum to determine whether BIT429 applies for the specific member/plan.

BIT429 flag controls plan-specific handling for listed codes; an 'X' indicates BIT429 = ON for that plan.
Example: E1700, E1701, E1702 and multiple J‑codes (J7604, J7607, J7609, J7610, J7615, etc.) show BIT429 = X for OK.
Providers must check member plan documents/addendum to confirm BIT429 applicability before billing.

Provider contractsIf a conflict arises between a CPCP and a provider contract, the provider contract will govern where applicable.

Examples of plan documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

DiscretionBCBSOK may use reasonable discretion interpreting and applying this policy; BCBSOK has final discretionary authority as provided under plan documents.

Reimbursement Information

TermReimbursement Information

UsageUsed as a header for tabulated lines that list codes, descriptions, effective dates and end dates in the policy.

PurposeIdentifies services and corresponding coding entries that are considered non‑reimbursable for claims processing.

Reimbursement code entry

FormatEach reimbursement line pairs a code with a short description and includes EFFECTIVE DATE and END DATE fields (e.g., G0281, DESCRIPTION = ELEC STIM UNATTEND FOR PRESS, EFFECTIVE DATE = 09/01/2020).

ContentLines cover CPT/HCPCS/temporary codes across multiple sections of the document and may include a blank END DATE when none is specified.

Examples0444T EFFECTIVE DATE = 12/01/2020 END DATE = 12/31/2022; G0281 EFFECTIVE DATE = 09/01/2020 END DATE = .

Operational noteUse these entries to determine whether a submitted code is listed as non‑reimbursable for the relevant service date.

Healthcare Common Procedure Coding System (HCPCS)

DefinitionHCPCS — Healthcare Common Procedure Coding System.

Source attributionHCPCS and CPT are referenced as standard coding systems used for claims and noted in the policy (CPT copyright acknowledged).

Usage in documentHCPCS codes are included in reimbursement listings and Plan Addendum sections to indicate code descriptions and plan applicability.