CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP028

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

Lists procedure, HCPCS and CPT Category III codes that Blue Cross Blue Shield of Oklahoma considers experimental, investigational or unproven and therefore non-reimbursable; applies to claim adjudication for BCBSOK members per plan documents and provider contracts.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP028

Change TypeAnnual update / code list maintenance

Effective DateJuly 1, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and use HIPAA-approved codes exactly as listed; listed codes will be denied as non-reimbursable without clinical review when submitted.

SourceLink

700+procedure/HCPCS/CPT codes listed as non-reimbursable in this part

400+distinct HCPCS/CPT/Q/S codes listed in this part

2024-07-01policy effective date

3.0policy version

multiplecodes with varied effective dates from 2020 to 07/01/2024

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.

Policy at a Glance

This policy, titled Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU), lists procedure, HCPCS and CPT Category III codes that Blue Cross Blue Shield of Oklahoma considers experimental, investigational or unproven and therefore non-reimbursable. It applies to claim adjudication for BCBSOK members and is used to identify codes that will be denied as non-reimbursable when submitted on a claim.

Policy effective date: July 1, 2024. Medical Policy Review Committee approval / last review: June 21, 2024.

procedure/HCPCS/CPT codes listed as non-reimbursable in this part700+

policy effective dateEffective 2024-07-01

policy versionVersion 3.0

distinct HCPCS/CPT/Q/S codes listed in this part400+

codes with varied effective dates from 2020 to 07/01/2024multiple

per-plan (state) activation flags includedPlan addendum (BIT429) with state-specific 'X' flags

Experimental / Investigational / Unproven (EIU) Coverage Statement

The purpose of this policy is to identify specific procedure and temporary/HCPCS codes that have been determined in the Coverage Statement of the Medical Policy to be experimental, investigational, or unproven and therefore do not require clinical review to determine coverage; listed codes will be denied as non-reimbursable when submitted on a claim.

Providers are responsible for submitting accurate documentation and coding using valid HIPAA-approved code sets; claims are subject to code-edit protocols and adjudication per plan documents, provider contracts, medical policies and coding software logic, and providers may be asked to supply additional documentation upon request.

Listed Codes and Coverage Status

CPT Category I and Category III procedure codesCPTNot Covered

17340	Cryotherapy of skin
20560	Needle injection without non-juxtamuscular - 1 or 2 muscles
20561	Needle injection without non-juxtamuscular - 3 or more muscles
20985	Computer-assisted direct muscle procedure (assistant?)
22526	IDET single level
22527	IDET 1 or more levels
22586	Prescral fusion with instrumentation L5-S1
22836	Anterior thoracic vertebral body tethering <7 segments
22837	Anterior thoracic vertebral body tethering 8+ segments
22838	Revision/replacement/removal thoracic vertebral tethering

1–10 of 95

1/10

HCPCS / CPT III / Category III / Temporary / G/C/Q/C codesHCPCS|CPT|TemporaryNot Covered

0052U	Lipoprotein blood with 5 major classes (U-code)
0054T	Bone surgery computer fluor image (T-code)
0055T	Bone surgery computer CT/MRI imaging (T-code)
0062U	AI SLE IgG IgM assay 80 biomarker
0063U	Neuro autism 32 amines algorithm
0066U	PAMG-1 immunoassay cervico-vaginal fluid
0100T	Prosthetic retina receive generator (T-code)
0101T	Extracorporeal shockwave therapy high energy (T-code)
0102T	Extracorporeal shockwave therapy anesthesia (T-code)
0106T	Touch quantitative sensory test (T-code)

1–10 of 143

1/15

HCPCS - A/C/E/C/Q/L/P etc. codesHCPCSNot Covered

A2001	Innovamatrix ac, per sq cm
A2002	Mirragen advanced wound matrix per sq cm
A2004	Xcellistem per sq cm
A2005	Microlyte matrix per sq cm
A2006	Novosorb synpath per sq cm
A2007	Restrata per sq cm
A2008	Theragenesis per sq cm
A2009	Symphony per sq cm
A2010	Apis per sq cm
A2011	Supras derm per sq cm

1–10 of 35

1/4

Misc HCPCS / C / E / L / Q / G / K / M / P / Q codes (selected examples)mixedNot Covered

C1052	Hemostatic agent, GI, topical
C1823	General neuro stimulation/stimulator
C1827	General neuro implant lead external connector
C1832	Autologous cell processing system
C1841	Retinal prosthesis internal external component
C1842	Retinal prosthesis add-on
C9092	Injection triamcinolone acetonide suprachoroidal (Xipere), 1 mg
C9354	Acellular pericardial tissue matrix
C9356	Tenoglide tendon protectant cm2
C9358	Dermal substitute native non-denatured

1–10 of 67

1/7

Listed HCPCS/CPT/Q/S/P codes with descriptions and effective dates (excerpt from part 2)mixed

K1033	Supplies for ultra diatherm.
K1036	Supplies for ultra diatherm.
L5991	Low pros ext osseo connector.
L8603	Collagen imp urinary 2.5 ml.
L8605	Injectable bulking agent dextranom.
L8608	ARG II EXT COM SUP ACC MISC.
M0076	Prolotherapy.
M0240	Casirivimab and imdevimab (repeat).
M0241	Casirivimab and imdevimab repeat (HM).
M0243	Casirivimab and imdevimab injection.

1–10 of 25

1/3

Plan Addendum - J and E codes (BIT429 flags per state)mixed

E1700	Jaw motion rehab system.
E1701	Replacement cushions for jaw motion.
E1702	Replacement measr scales jaw motion.
J7604	Acetylcysteine comp unit.
J7607	Levalbuterol comp con.
J7609	Albuterol comp unit.
J7610	Albuterol comp con.
J7615	Levalbuterol comp unit.

Billing, Documentation and Claim Submission Requirements

Billing Rule

Claims submission and coding requirements

Providers must submit accurate documentation and use valid HIPAA-approved code combinations. Claims will be adjudicated according to plan documents, provider contracts, medical policies and code-edit protocols; listed codes will be denied as non-reimbursable without clinical review when submitted.

Documentation Required

Provision of additional documentation

Upon request, providers are urged to submit any additional documentation to support services billed; BCBSOK may use discretion in interpreting and applying the policy to particular cases.

Defined Terms

Experimental, Investigational and/or Unproven (EIU)Services determined in the Coverage Statement of the Medical Policy to be experimental/investigational/or unproven and therefore non-reimbursable; these do not require clinical review to determine coverage when submitted as the listed codes.

BIT429Plan-specific flag column indicating whether a code is active for that plan/state (X = active).

Effective Date / End DateDates shown indicate when a code becomes effective for reimbursement and when it is end-dated (if present).

Policy Dates & Changes

Policy effective date: July 1, 2024. Last review / Medical Policy Review Committee approval: June 21, 2024.