CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO28

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

This policy lists procedure, CPT, and HCPCS codes that BCBS Oklahoma considers experimental, investigational, or unproven and therefore non‑reimbursable when submitted on claims; it governs claims/payment determinations for BCBSOK members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCPO28

Change TypeNo material change

Effective DateDec 1, 2023

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+codes listed as non-reimbursable in this excerpt

12/01/2023policy effective date

20+CPT/HCPCS/T-code entries shown

OKPlan addendum includes OK flags

partialdocument segment

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 Determinations & Code Listings

Non‑Reimbursable Determination

Codes listed in the policy are denied as non‑reimbursable when submitted on a claim per the member's plan documents.

Services (procedure codes or categories of codes) explicitly determined to be experimental, investigational, or unproven are denied as non‑reimbursable when submitted on a claim; denial is based on the member's plan documents and does not require clinical review to determine coverage.

Reimbursement code references (partial)

Code listing for reimbursement reference; no explicit criteria or determinations are present in these chunks.

This segment provides CPT/HCPCS/T code listings with descriptions and EFFECTIVE DATE/END DATE fields for reimbursement reference; the segment does not include per‑code clinical criteria or coverage decisions within these chunks.

Enumerated codes (coverage stance not specified here)

Code listing excerpt (no explicit coverage decision text in these chunks).

Enumerated CPT/HCPCS and miscellaneous codes (including procedure, supply and product codes) are listed with descriptions and effective/end dates; these chunks present the code listings but do not state explicit per‑code coverage determinations or clinical criteria.

Coding and Plan Addendum Listings

Code listings and plan addenda entries (no explicit coverage criteria in this segment).

HCPCS and plan addendum code entries are enumerated with EFFECTIVE DATE and END DATE fields where available; plan‑specific flags (e.g., OK) appear in the plan addendum. This segment contains coding and addendum listings but does not include specific coverage criteria.

Code Tables and Effective/End Dates

Examples of non-reimbursable codes (partial list)mixedNot Covered

17340	CRYOTHERAPY OF SKIN
20560	NDL INSJ W 0 NJX 1 OR 2 MUSC
28890	HI ENRGY ESWT PLANTAR FASCIA
36473	ENDOVENOUS MCHNCHEM 1ST VEIN
83695	ASSAY OF LIPOPROTEIN(A)
86328	IA NFCT AB SARSCOV2 COVID19

Sample T-code entries (continued list in document)mixed

0445T	SBSQT PLMT DRUG ELUT OC INS
0464T	VISUAL EP TEST FOR GLAUCOMA
0472T	PRGRMG I0 RTA ELTRD RA

Mixed T-/A-/C-series entriesmixed

0770T	VR TECHNOLOGY ASSIST THERAPY
A2019	Kerecis marigen shld sq cm
C9092	Injection, triamcinolone acetonide, suprachoroidal (xipere) 1 mg

E- and K-series device/supply codesmixed

E0490	Power source/control electronics unit for oral device/appliance for neuro musc elec stim tongue muscle
E0764	FUNCTIONAL NEUROMUSCULARSTIM
K1002	CRANIAL ELECTROTHERAPY STIMULATION

Examples of codes listed in this segmentmixedExperimental

60295	ELECTROMAGNETIC THERAPY ONC
60428	COLLAGEN MENISCUS IMPLANT PROCEDURE
K1002	CRANIAL ELECTROTHERAPY STIMULATION
K1036	Supplies/accessories low freq ultrasonic diathermy per month
L5991	Add to lower ext prostheses, osseointegrated ext prost connector
Q4103	Oasis burn matrix
Q4137	Amnioexcel biodexcel 1sq cm
Q4199	Cygnus matrix, per sq cm
Q4262	Dual layer impax, per sq cm

Listed HCPCS/S codes with descriptions and effective datesHCPCS

Q4258	Celera per sq cm (effective 04/01/2022)
Q4259	Celera per sq cm (effective 01/01/2023)
Q4260	Signature apatch, per sq cm (effective 01/01/2023)
Q4262	Dual layer impax, per sq cm (effective 01/01/2023)
Q4265	Neostim tl per sq cm (effective 09/01/2023)
Q4272	Esano a, per sq cm (effective 12/01/2023)
Q4273	Esano aaa, per sq cm (effective 12/01/2023)
Q4280	Xcell amnio matrix, per sq cm (effective 12/01/2023)
S2117	ARTHROEREISIS SUBTALAR (effective 12/01/2020)
S2300	ARTHROSCOPY SHOULDER SURGI (effective 12/01/2020)

1–10 of 15

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Codes with end dates

Examples of codes with specific end dates0445T — END DATE 12/31/2022; C9092 — END DATE 06/30/2022; C1841/C1842 — END DATE 12/31/2022

Other end-dated entries shown0465T — END DATE 09/14/2022; 0632T — END DATE 06/30/2023

Most codes have END DATE blank when not end-datedMany entries list END DATE = . indicating no end date set in the table

Effective date presence

EFFECTIVE DATE present for each listingMost code entries include an EFFECTIVE DATE field showing when the code was added to the reimbursement table (e.g., 60295 EFFECTIVE DATE = 09/01/2020)

Billing, Claims, and Documentation Guidance

Documentation Required

Claims coding and documentation

Providers must submit claims using valid HIPAA-approved code sets and code appropriately per industry standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI). Claims are subject to claim review and code-edit protocols; upon request providers must supply additional documentation to support the claim.

Submit claims with HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG)
Follow AMA, CPT Assistant, UB Editor, CMS NCCI and other applicable coding guidance
Be prepared to provide supporting documentation upon request

Billing Rule

Reimbursement code list (partial)

Partial reimbursement code list from source. Use for reference when billing; verify effective/end dates and carrier-specific edits at time of billing.

Key Terms and Coding Fields

Experimental/Investigational/Unproven (EIU)

Definition of EIU servicesServices (procedure codes or categories of codes) explicitly determined to be experimental, investigational, or unproven and denied as non‑reimbursable when submitted on a claim

Scope of codes includedIncludes CPT Category I, CPT Category III (temporary emerging technology codes), and HCPCS codes listed as EIU

Claim-level denial applicationCodes listed are denied as non‑reimbursable without requirement for clinical review per the Coverage Statement

Reimbursement Information

Reimbursement entry formatEntries present code, description, EFFECTIVE DATE, and END DATE where provided (e.g., 0445T, DESCRIPTION = SBSQT PLMT DRUG ELUT OC INS, EFFECTIVE DATE = 12/01/2020, END DATE = 12/31/2022)

Mixed code series included

Policy Update History

2023-09-27code_additionLatest

Added HCPCS codes effective 10/01/2023.

2023-08-07code_end_date_and_addition

End‑dated codes 06/30/2023 and added HCPCS codes effective 12/01/2023.

2023-05-25code_addition

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCPO28

Change TypeNo material change

Effective DateDec 1, 2023

Next Review Date

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

SourceLink

On This Page

END DATE may be blankMany EFFECTIVE DATE entries are followed by END DATE = . when no end date is set (e.g., K1002 END DATE = .)

Both HCPCS and CPT Category III/T codes use EFFECTIVE DATET-, S-, Q- and other series codes in the list also include EFFECTIVE DATE fields

Code effective date changes

Multiple effective-date additions across 2020–2023Policy Update History records additions and effective date revisions from 2020 through 09/27/2023 (examples: codes added eff 01/01/2023, 04/01/2022, 09/01/2020)

End-dating events recordedUpdate history documents end-dating of codes on specific dates (e.g., end-dated codes 06/30/2023; end-dated codes 12/31/2022)

Effective date revisions notedEntries include revised effective dates (e.g., revised from 07/01/2023 to 09/01/2023) showing active maintenance of code list

0445T — SBSQT PLMT DRUG ELUT OC INS (Effective 12/01/2020 – End 12/31/2022)
0464T — VISUAL EP TEST FOR GLAUCOMA (Effective 12/01/2020)
0465T — SUPCHRDL NJX RX W/o SUPPLY (Effective 09/01/2020 – End 09/14/2022)
0472T — PRGRMG I0 RTA ELTRD RA (Effective 12/01/2020)
0473T — REPRGRMG I0 RTA ELTRD RA (Effective 12/01/2020)

Note

Code list (no authorization actions specified)

Additional code listings from source (no authorization actions specified). These codes and descriptions are included for billing reference; confirm current status/effective dates before submission.

ELECT STIM UNATTEND FOR PRESS (Effective 09/01/2020)
ELECT STIM WOUND CARE NOT PD (Effective 09/01/2020)
60295 — ELECTROMAGNETIC THERAPY ONC (Effective 09/01/2020)
60329 — ELECTROMAGNETIC TX FOR ULCERS (Effective 09/01/2020)
60428 — COLLAGEN MENISCUS IMPLANT PROCEDURE (Effective 12/01/2020)
60460 — AUTOLOGOUS PRP FOR ULCERS (Effective 12/01/2020)
60465 — AUTOLOG PRP DIAB WOUND ULCER (Effective 04/15/2022)
69147 — OUTPATIENT INTRAVENOUS INSULIN TREATMENT (Effective 12/01/2020)
K1002 — CRANIAL ELECTROTHERAPY STIMULATION (Effective 12/01/2020)
K1004 — LO FREQ US DIATHERMY DEVICE (Effective 12/01/2020)
K1007 — Bil hkaf pc s/d micro sensor (Effective 03/01/2021)

Note

Billing/coding updates (informational)

Policy update history (informational). Providers should reference these dated changes when validating code effective dates and termination dates prior to billing.

09/27/2023 — Added HCPCS codes effective 10/01/2023
08/07/2023 — End-dated codes 06/30/2023; Added HCPCS codes effective 12/01/2023
05/25/2023 — Added HCPCS codes effective 09/01/2023
05/26/2023 — Added new CPT/HCPCS codes effective 07/01/2023; Revised effective date to 09/01/2023
05/26/2023 — End-dated code 06/30/2023; Added CPT/HCPCS codes effective 06/01/2023
03/24/2023 — Added CPT/HCPCS codes effective 07/01/2023; Removed codes end-dated 12/31/2020, 09/30/2021, 12/31/2021, 12/31/2022
12/20/2022 — End-dated codes 12/31/2022; Added new CPT/HCPCS codes effective 01/01/2023; CPT/HCPCS codes 04/01/2023
09/22/2022 — Added CPT/HCPCS codes effective 01/01/2023
04/22/2022 — Added CPT/HCPCS codes effective 08/01/2022
03/29/2022 — Added HCPCS codes effective 04/01/2022
01/27/2022 — Code end-dated 01/31/2022
01/10/2022 — Added CPT/HCPCS codes effective 04/15/2022; Code end-dated 10/14/2021
05/12/2021 — Added CPT/HCPCS codes effective 08/15/2021
01/28/2021 — Added CPT/HCPCS codes effective 05/15/2021; Removed codes end-dated 12/31/2020
11/05/2020 — Added/Removed CPT/HCPCS codes (AMA changes effective 01/01/2021)
10/30/2020 — Added/Removed CPT/HCPCS codes effective 03/01/2021

List contains T-, S-, Q-, K-, C-, A-, E-, and numeric CPT/HCPCS codes with their reimbursement information

Policy applies these listings to claims adjudicationThe listed reimbursement information is used to identify services that are non‑reimbursable per the policy

EFFECTIVE DATE

EFFECTIVE DATE meaningThe EFFECTIVE DATE indicates when the code listing entered the payer's reimbursement table (example: 60295 EFFECTIVE DATE = 09/01/2020)

Used for billing referenceProviders should reference EFFECTIVE DATE when determining applicability of a code listing

Present across code seriesEFFECTIVE DATE fields appear for CPT, HCPCS, and temporary Category III/T codes in the listing

END DATE

END DATE presenceSome codes include an END DATE value specifying when the listing was removed or retired (e.g., 0445T END DATE = 12/31/2022; 0632T END DATE = 06/30/2023)

Blank when activeEND DATE = . indicates no end date set and the code remains listed as of the document segment

End-dating recorded in update historyPolicy Update History documents code end-dating events and specific end-dates

CPT/HCPCS copyright notice

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

HCPCS referenceHCPCS is referenced as the Healthcare Common Procedure Coding System

Added HCPCS codes effective 09/01/2023.

2023-05-26code_addition_and_revision

Added new CPT/HCPCS codes effective 07/01/2023 and revised effective dates of CPT/HCPCS codes from 07/01/2023 to 09/01/2023.

2023-05-26code_end_date_and_addition

End‑dated code 06/30/2023 and added CPT/HCPCS codes effective 06/01/2023.

2023-03-24code_addition_and_removal

Added CPT/HCPCS codes effective 07/01/2023 and removed CPT/HCPCS codes with multiple end dates (including 12/31/2020, 09/30/2021, 12/31/2021, 12/31/2022).

2022-12-20code_end_date_and_addition

End‑dated codes 12/31/2022; added new CPT/HCPCS codes effective 01/01/2023 and additional CPT/HCPCS codes effective 04/01/2023.

2022-09-22code_addition

Added CPT/HCPCS codes effective 01/01/2023.

2022-04-22code_addition

Added CPT/HCPCS codes effective 08/01/2022.

2022-03-29code_addition

Added HCPCS codes effective 04/01/2022.

2022-01-27code_end_date

Code end‑dated 01/31/2022.

2022-01-10code_addition_and_end_date

Added CPT/HCPCS codes effective 04/15/2022 and end‑dated a code 10/14/2021.

2021-05-12code_addition

Added CPT/HCPCS codes effective 08/15/2021.

2021-01-28code_addition_and_removal

Added CPT/HCPCS codes effective 05/15/2021 and removed CPT/HCPCS codes end‑dated 12/31/2020.

2020-11-05code_addition_removal

Added and removed CPT/HCPCS codes per AMA changes effective 01/01/2021.

2020-10-30code_addition_removal

Added/removed CPT/HCPCS codes effective 03/01/2021.