CurrentPremera BluecrossPolicy N/A

Non-covered Services and Procedures

Lists categories of services, supplies, and specific procedure/product codes that Premera Blue Cross does not cover under the member's plan; intended for providers submitting claims or ordering services.

Policy Summary

PayerPremera Bluecross

PolicyNon-covered Services and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization for services not specifically listed as covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150+CPT/HCPCS codes enumerated as non-covered examples

multipleTypes of non-covered services listed

nationalApplicability

MedicareAdvScope exclusion noted

Coverage Criteria — Non‑Covered Services

General Non-covered Services

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.

Services listed are non-covered unless an exception (e.g., reconstructive services meeting medical necessity) applies.

Non-covered categories: Services or supplies that are cosmetic, custodial, nonmedical, nonprescription (over-the-counter), personal care/convenience items, or nonmedical equipment (DME/HME that does not meet the definition of medically necessary) are not covered.

Exceptions: cosmetic services that are reconstructive may be covered when medical necessity criteria are met; member's contract prevails.

Not Covered / Special Billing Notes

Codes specifically called out in the list are designated as noncovered or have special billing notes.

Noncovered / Special Note Codes: Items and services represented by codes explicitly listed with 'Noncovered' notes or identified as noncovered in the coding tables (examples include A0888, G0293/G0294, S0800 for LASIK) are not payable under this policy excerpt.

Treat each listed code per its specific note in the coding section; consult coding tables for complete list.

Non-covered conditions (contract-based)

Not covered when ANY of the following contract-based conditions are present:

Non-covered conditions: Services, supplies, drugs, and medications furnished in connection with or directly related to any condition, service, or supply that is not covered under the member's contract; services related to a benefit that has been exhausted; any service or supply not specifically listed as covered unless preauthorized by the plan; amounts that exceed the allowable charge or maximum benefit for a covered service; experimental or investigational services (except limited clinical trial exceptions); and services covered by other sources (e.g., motor vehicle or liability insurance).

Coverage determinations require verification of the member benefit booklet and the service date; this policy does not apply to Medicare Advantage.

Direct or indirect complications and aftereffects from services that are excluded as cosmetic are not covered under the plan. The policy identifies several broad non-covered categories including cosmetic services, custodial care, nonmedical equipment, and nonprescription (over-the-counter) drugs, supplements, or supplies. These categories are illustrative and not exhaustive; exceptions (for example, reconstructive procedures that meet medical necessity criteria) may apply when supported by the member's contract and clinical documentation. When there is a conflict between this list and the member's contract, the member's contract prevails.

Although many durable medical equipment and supply HCPCS codes are presented among non-covered items, the policy specifically notes that an electric breast pump is covered for women's health (E0602). Providers should document the indication and code accurately to reflect this exception and avoid inappropriate denials.

The lists of non-covered services and example codes in this policy are illustrative, not exhaustive. Coverage for any specific item or service is determined by the member's benefit contract and the date of service. Providers and billing staff should consult the member benefit booklet or contact member services to confirm whether a particular service or supply is covered for the enrollee in question.

This medical policy does not apply to members enrolled in Medicare Advantage plans. For Medicare Advantage coverage determinations, follow the applicable Medicare Advantage plan policies and contract terms.

The policy defines cosmetic services as services that alter appearance or shape and that do not relieve pain or improve, correct, or restore physical function. Such services are considered not medically necessary and are not covered, except when a procedure is reconstructive and meets the plan's medical necessity criteria. Related complications or aftereffects of excluded cosmetic services are also not covered.

The policy lists example code S8990 described as "Physical or manipulative therapy performed for maintenance rather than restoration." This service is commonly identified in the policy as not medically necessary when billed as maintenance rather than restorative therapy.

Experimental or investigational services are excluded from coverage under this policy. An exception may be made for services provided as part of a clinical trial when the member meets the trial enrollment criteria; otherwise such services are treated as non-covered.

Coding — Non‑Covered and Example Codes

Example not-covered CPT Category III codesCPTNot Covered

0517U	Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC-MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non-prescribed medications.
0518U	Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC-MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non-prescribed medications.
0519U	Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC-MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non-prescribed, and illicit medications in circulation

Assorted Category III and other temporary codesCPTNot Covered

0520U	Therapeutic drug monitoring, 200 or more drugs or substances, LC-MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non-prescribed medications.
0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional.
0662T	Scalp cooling, mechanical; initial measurement and calibration of cap.
0663T	Scalp cooling, mechanical; placement of device monitoring and removal of device (code termed 01/01/26).
0753T	Digitization of glass microscope slides for level IV, surgical pathology, gross and microscopic examination (List separately in addition to code for primary procedure).
0827T	Digitization of glass microscope slides for cytopathology, fluids, washings, or brushings, except cervical or vaginal; smears with interpretation (List separately in addition to code for primary procedure).
0831T	Digitization of glass microscope slides for cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician (List separately in addition to code for primary procedure).
0836T	Digitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure).
0841T	Digitization of glass microscope slides for pathology consultation during surgery; first tissue block, with frozen section(s), single specimen (List separately in addition to code for primary procedure).

Cosmetic/sex-reassignment and related proceduresCPTNot Covered

15775	Punch graft for hair transplant; 1 to 15 punch grafts.
15776	Punch graft for hair transplant; more than 15 punch grafts.
17380	Electrolysis epilation, each 30 minutes.
54231	Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (e.g., papaverine, phentolamine).
54400	Insertion of penile prosthesis; non-inflatable (semi-rigid).
54405	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir.
69090	Ear piercing

Miscellaneous diagnostic, safety, and administrative CPT codesCPTNot Covered

76014	MR safety implant and/or foreign body assessment by trained clinical staff.
76016	MR safety determination by a physician or other qualified health care professional with written report.
86910	Blood typing for paternity testing.
88000	Necropsy (autopsy), gross examination only; without CNS.
88020	Necropsy (autopsy), gross and microscopic; without CNS.
97007	Mechanical scalp cooling, including individual cap supply with head measurement, fitting, and patient education (new code effective 01/01/26).
99080	Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form.
99450	Basic life and/or disability examination including collection of blood sample and/or urinalysis complying with chain of custody protocols.

HCPCS non-covered items and suppliesHCPCSNot Covered

A0080	Nonemergency transportation, per mile - vehicle provided by volunteer.
A0100	Nonemergency transportation; taxi.
A0130	Nonemergency transportation: wheelchair van.
A4244	Alcohol or peroxide, per pint.
A6530	Gradient compression stocking, below knee, 18-30 mm Hg, each.
A9150	Nonprescription drugs.
A9270	Noncovered item or service.
A9273	Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type.

Listed HCPCS A-codes (transportation, supplies)HCPCSNot Covered

A0100	Nonemergency transportation; taxi
A0110	Nonemergency transportation and bus, intra- or interstate carrier
A0120	Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems
A0130	Nonemergency transportation: wheelchair van
A0160	Nonemergency transportation: per mile - caseworker or social worker
A0170	Transportation ancillary: parking fees, tolls, other
A0180	Nonemergency transportation: ancillary: lodging-recipient
A0190	Nonemergency transportation: ancillary: meals, recipient
A0200	Nonemergency transportation: ancillary: lodging, escort
A0210	Nonemergency transportation: ancillary: meals, escort

1–10 of 11

1/2

Listed HCPCS A-codes (supplies, monitoring devices, stockings)HCPCSNot Covered

A4244	Alcohol or peroxide, per pint
A4246	Betadine or pHisoHex solution, per pint
A4247	Betadine or iodine swabs/wipes, per box
A4335	Incontinence supply; miscellaneous
A4520	Incontinence garment, any type, each
A4553	Non-disposable underpads, all sizes
A4554	Disposable underpads, all sizes
A4563	Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each
A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663	Blood pressure cuff only

1–10 of 15

1/2

Listed HCPCS E-codes (durable medical equipment, DME)HCPCSNot Covered

E0150	Combination wheeled walker with seat and transport chair, folding, adjustable or fixed height (new code effective 10/01/25)
E0170	Commode chair with integrated seat lift mechanism, electric, any type
E0171	Commode chair with integrated seat lift mechanism, nonelectric, any type
E0172	Seat lift mechanism placed over or on top of toilet, any type
E0175	Footrest, for use with commode chair, each
E0190	Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
E0201	Penile contracture device, manual, greater than 3 lbs. traction force (new code effective 04/01/25)
E0240	Bath/shower chair, with or without wheels, any size
E0574	Ultrasonic/electronic aerosol generator with small volume nebulizer
E0602	Breast pump, manual

1–10 of 11

1/2

Listed HCPCS E- and G-codes (DME and community health services)HCPCS

E1015	Shock absorber for manual wheelchair, each
E1016	Shock absorber for power wheelchair, each
E1022	Wheelchair transportation securement system, any type, includes all components and accessories (new code effective 04/01/25)
E1300	Whirlpool, portable (overtub type)
E1570	Adjustable chair for ESRD patients
E1902	Communication board, nonelectronic augmentative or alternative communication device
G0019	Community health integration services performed by certified or trained auxiliary personnel, 60 minutes per calendar month
G0022	Community health integration services, each additional 30 minutes per calendar month
G0136	Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5 to 15 minutes

Listed G-codes (clinical trial noncovered)HCPCSNot Covered

G0293	Noncovered surgical procedure(s) using conscious sedation, regional, general, or spinal anesthesia in a Medicare qualifying clinical trial, per day
G0294	Noncovered procedure(s) using either no anesthesia or local anesthesia only, in a Medicare qualifying clinical trial, per day

Listed H-codes (behavioral health)HCPCS

H0002	Behavioral health screening to determine eligibility for admission for a treatment program
H0006	Alcohol and/or drug services; case management
H0021	Alcohol and/or drug training service (for staff and personnel not employed by providers)
H0048	Alcohol and/or other drug testing: collection and handling only, specimens other than blood

Listed M/P/Q-codes (infusions, tests, injections)HCPCS

M0249	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients with COVID-19 includes infusion and post administration monitoring, first dose
M0250	Intravenous infusion, tocilizumab ... second dose
P2031	Hair analysis (excluding arsenic)
Q0249	Injection, tocilizumab, for hospitalized adults and pediatric patients with COVID-19, 1 mg

Listed S-codes (elective procedures, services, trial-related costs)HCPCSNot Covered

S0800	Laser in situ keratomileusis (LASIK)
S0810	Photorefractive keratectomy (PRK)
S0315	Disease management program; initial assessment and initiation of the program
S0316	Disease management program, follow-up/reassessment
S9992	Transportation costs to and from trial location and local transportation costs for clinical trial participant and one caregiver/companion
S9994	Lodging costs for clinical trial participant and one caregiver/companion

Listed S- and T-codes (therapy, memberships, supplies)HCPCSNot Covered

S8990	Physical or manipulative therapy performed for maintenance rather than restoration
S9970	Health club membership, annual
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes
T1015	Clinic visit/encounter, all-inclusive
T4521	Adult sized disposable incontinence product, brief/diaper, small, each
T4535	Disposable liner/shield/guard/pad/undergarment, for incontinence, each

Non-covered HCPCS/T codes (partial list)HCPCSNot Covered

T2051	Supports brokerage, self-directed, waiver; per diem.
T2101	Human breast milk processing, storage, and distribution only.
T4521	Adult sized disposable incontinence product, brief/diaper, small, each.
T4522	Adult sized disposable incontinence product, brief/diaper, medium, each.
T4523	Adult sized disposable incontinence product, brief/diaper, large, each.
T4524	Adult sized disposable incontinence product, brief/diaper, extra-large, each.
T4525	Adult sized disposable incontinence product, protective underwear/pull-on, small size, each.
T4526	Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each.
T4527	Adult sized disposable incontinence product, protective underwear/pull-on, large size, each.
T4528	Adult sized disposable incontinence product, protective underwear/pull-on, extra-large size, each.

1–10 of 13

1/2

Non-covered HCPCS/T codes (continued)HCPCSNot Covered

T4532	Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each.
T4533	Youth sized disposable incontinence product, brief/diaper, each.
T4534	Youth sized disposable incontinence product, protective underwear/pull-on, each.
T4535	Disposable liner/shield/guard/pad/undergarment, for incontinence, each.
T4536	Incontinence product, protective underwear/pull-on, reusable, any size, each.
T4537	Incontinence product, protective under pad, reusable, bed size, each.
T4538	Diaper service, reusable diaper.
T4539	Incontinence product, diaper/brief, reusable, any size, each.
T4540	Incontinence product, protective under pad, reusable, chair size, each.
T4541	Incontinence product, disposable under pad, large, each.

1–10 of 15

1/2

Not-covered V codes and assistive devicesHCPCSNot Covered

V2526	Contact lens, hydrophilic, with blue-violet filter, per lens.
V2615	Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system.
V2756	Eye glass case.
V2787	Astigmatism correcting function of intraocular lens.
V2788	Presbyopia correcting function of intraocular lens.
V5269	Assistive listening device, any type.
V5270	Assistive listening device, television amplifier, any type.
V5271	Assistive listening device, television caption decoder.
V5272	Assistive listening device, TDD.
V5273	Assistive listening device, for use with cochlear implant.

1–10 of 11

1/2

Revenue codes listed in the guidelineRevenueNot Covered

0902	Milieu therapy (Revenue code).
0907	Community behavioral health program (day treatment) (Revenue code).
0941	Recreational Therapy (Revenue code).
0951	Athletic Training (Revenue code).
0952	Kinesiotherapy training (Revenue code).
0990	Patient Convenience Items - General Classification (Revenue code).
0991	Charges for Cafeteria/Guest Trays (Revenue code).
0992	Charges for Private Linen Service (Revenue code).
0993	Charges for Telephone/Telegraph (Revenue code).
0994	TV/Radio (Revenue code).

1–10 of 20

1/2

Number of analytes for therapeutic drug monitoring codes

Therapeutic drug monitoring panels (0517U)Described as 80 or more psychoactive drugs/substances (LC-MS/MS, plasma)

Therapeutic drug monitoring panels (0518U)Described as 90 or more pain and mental health drugs/substances (LC-MS/MS, plasma)

Therapeutic drug monitoring panels (0519U)Described as 110 or more drugs/substances for pain, depression, and anxiety (LC-MS/MS, plasma)

Therapeutic drug monitoring panels (0520U)Described as 200 or more drugs/substances (LC-MS/MS, plasma)

Compression stockings (pressure and examples)

Compression stocking pressure range18-30 mm Hg (listed for multiple gradient compression stocking HCPCS codes such as A6530, A6533, A6536, A6539, A6610)

Stocking types referencedBelow knee, thigh length, full-length/chap style, waist length, custom options

Associated HCPCS examplesA6530, A6533, A6536, A6539, A6610

Numeric clinical thresholds

No numeric clinical thresholds providedThis section of the policy does not define numeric clinical thresholds for coverage determinations; coverage is determined by contract, medical necessity, and prior authorization where applicable.

Policy scope noteCoverage decisions rely on member contract effective date and date of service rather than numeric clinical cutoffs.

Exceptions and limitsExperimental/investigational exceptions and clinical trial criteria are described separately; numeric thresholds are not presented here.

Provider Actions — Billing, Documentation, and Authorization

Prior Authorization

Preauthorization Required / Verify Member Benefits

Prior authorization requirements vary by contract and service date. Some services are subject to preauthorization; verify the member's contract and obtain prior authorization when required. Services not listed as covered may be denied if not preauthorized.

Coverage depends on member contract effective date and service date.
If a service or supply is not specifically listed as covered, preauthorization is required.
Preauthorization may be required for services related to clinical trials per contract terms.

Prior Authorization

Prior Authorization / Trial Billing Caution

Claims for services provided in Medicare qualifying clinical trials may include codes that are noncovered (e.g., G0293, G0294). When billing for trial-related services, confirm coverage policy and trial billing rules before submitting claims to avoid denials.

Do not assume trial-related codes are covered — G0293 and G0294 are listed as noncovered for Medicare qualifying clinical trials.
Confirm whether an exception applies for eligible clinical trial participation.
When in doubt, contact member services or medical policy for guidance.

Denial Risk

Denial Risk from Billing Noncovered HCPCS

Use of HCPCS codes that are explicitly listed as non-covered will trigger claim denial. Review the policy code list and member contract before billing. Related supplies or drugs furnished in connection with a non-covered item may also be denied.

Examples of non-covered HCPCS include A0888 and multiple DME/A‑series codes listed in the policy.
Related supplies/drugs for a non-covered item are subject to denial.
Amounts exceeding allowable charge or maximum benefit may be denied.

Prior Authorization

Preauthorization Required for Non‑Listed Services

If a service or supply is not specifically listed as covered, obtain preauthorization before providing or billing for it. Failure to secure preauthorization can result in claim denial, especially for services considered experimental/investigational or not medically necessary under the member contract.

Services not listed as covered require preauthorization.
Experimental or investigational services are excluded except for certain clinical trial exceptions.
Denials may occur without preauthorization, for exhausted benefits, or when charges exceed plan limits.

Covered Indications / Examples

Therapeutic Drug Monitoring LC-MS/MS Panels (Non-covered Examples)

The following high-complexity therapeutic drug monitoring LC-MS/MS panels are provided as examples of non-covered laboratory services.

Non-covered LC-MS/MS panels: CPT codes 0517U, 0518U, 0519U, and 0520U (therapeutic drug monitoring multi-analyte LC-MS/MS panels; e.g., panels for ~80, 90, 110, and 200+ drugs/substances) are listed among non-covered examples.

These codes are presented as non-covered examples in the coding tables of the policy excerpt.

Hair Analysis (P2031) — Coding Note

Hair analysis is listed in the coding tables without supporting clinical coverage criteria in this excerpt.

Hair analysis (P2031): HCPCS code P2031 (Hair analysis, excluding arsenic) is included in the coding list; no clinical indications or medical necessity criteria are provided in this policy excerpt to support coverage.

Determine coverage by member contract or full policy context; prior authorization or additional documentation may be required by the plan.

Frequency Limits and Test-specific Notes

Hair analysis (P2031) — frequency and coverage note

Hair analysis codeP2031 — Hair analysis (excluding arsenic)

Frequency criteriaNo clinical frequency limits or testing interval specified in the policy excerpt

Coverage status in excerptListed among codes; no supporting clinical indication provided in this excerpt (coverage may depend on full policy or member contract)

Ordering Requirements

Note

Ordering requirements: no specific provider restrictions in excerpt

No ordering-provider restrictions are specified in this excerpt.

Note

Ordering requirements: no explicit restrictions provided

The excerpt provides no explicit ordering-provider restrictions.

Step Therapy

Ordering requirements: verify benefits and obtain prior authorization when needed

Providers must consult the member benefit booklet or contact Member Services to determine coverage for a test or supply; prior authorization may be required for services not specifically listed as covered.

Verify coverage via member booklet or Member Services.
Obtain prior authorization when required for services not listed as covered.

Not Covered — Selected Tests and Services

Certain high-complexity therapeutic drug monitoring panels (for example, CPT codes 0517U–0520U) are presented in the coding section as examples of services that are not covered. These multi-analyte LC-MS/MS panels (noted for very large analyte counts) are among the laboratory/pathology codes identified as non-covered in the policy excerpt.

Necropsy and autopsy CPT codes (including examples from the 88000–88037 series) are listed among the non-covered examples in the coding tables and are considered non-covered per the policy excerpt.

Hair analysis represented by HCPCS code P2031 (excluding arsenic) appears in the coding list but the excerpt provides no supporting clinical indication for coverage. As such, coverage for P2031 may be denied or determined non-covered depending on the member's contract and the full policy context.

The coding sections include numerous HCPCS T and V codes and other supply codes for items such as disposable incontinence products, assistive devices, and other supplies. These HCPCS/T and V codes are presented in the policy as examples of non-covered supplies and should be billed only when coverage is verified under the member's contract.

Background

Medical coding systems (CPT, HCPCS, ICD-10) identify specific services, supplies, and diagnoses, but not all coded services meet the plan's definition of medically necessary. The policy clarifies that services listed or billed with codes designated as non-covered will be denied unless the member contract or an authorized exception indicates coverage.

Definitions

Cosmetic — definition and coverage stance

DefinitionCosmetic: A service that alters the appearance or shape of a body part and does not relieve pain or improve, correct, or restore physical function.

Coverage stanceCosmetic services are not covered unless they qualify as reconstructive and meet medical necessity criteria.

Related exclusionsDirect or indirect complications and aftereffects from non-covered cosmetic services are not covered.

Custodial care — definition

DefinitionCustodial care: Care that does not require the regular services of a trained medical or allied health care professional and primarily assists with activities of daily living (e.g., bathing, dressing, help with walking).

Coverage stanceCustodial care is not covered under the policy excerpt.

ExamplesAssistance with activities of daily living such as getting in and out of bed, bathing, dressing.

Nonprescription drugs and supplies

DefinitionNonprescription (over-the-counter) drugs, supplements, or supplies: Products that can be purchased without a prescription.

Coverage stanceNonprescription drugs and supplies are not covered.

Example HCPCSA9150 = Nonprescription drugs (listed as non-covered)

Codes explicitly designated as noncovered

Explicit noncovered HCPCS examplesA0888 (Noncovered ambulance mileage), A9270 (Noncovered item or service), G0293 (Noncovered surgical procedure in Medicare qualifying clinical trial)

Supplies examplesA4244 (Alcohol or peroxide), A4931 (Oral thermometer), A6530 (Gradient compression stocking)

Clinical trial codesG0293 and G0294 are listed as noncovered in the context of Medicare qualifying clinical trials; verify trial billing rules before submission.

Non-covered services — policy definition and implications

DefinitionNon-covered services: Services not included in a member's contract, services related to exhausted benefits, services not specifically listed as covered unless preauthorized, amounts exceeding allowable charges, or services considered experimental/investigational.

Member contract precedenceIf there is a difference between the table and the member's contract, the member's contract prevails; coverage is dependent on contract effective date and date of service.

Action for providersConsult the member benefit booklet or member services to determine coverage for a specific service or supply.

Clinical trial exception and related notes

Clinical trial exception possibilityAn exception may be allowed for participation in a clinical trial when enrollment criteria are met; however certain codes (e.g., G0293/G0294) are called out as noncovered for Medicare qualifying clinical trials—verify trial billing rules.

Experimental/investigational exclusionExperimental or investigational services are excluded and may be denied except for specific clinical trial exceptions.

Provider actionConfirm trial enrollment criteria and prior authorization or billing guidance before submitting claims for clinical trial–related services.

Policy Summary

PayerPremera Bluecross

PolicyNon-covered Services and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization for services not specifically listed as covered.

SourceLink

On This Page