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If a conflict arises between a Clinical Payment and Coding Policy (“CPCP”) and any plan document under which a memberis entitled to Covered Services, the plan document will govern. If a conflict arises between a CPCP and any providercontract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans,the provider contract will govern. “Plan documents” include, but are not limited to, Certificates of Health Care Benefits,benefit booklets, Summary Plan Descriptions, and other coverage documents. BCBSNM may use reasonable discretioninterpreting and applying this policy to services being delivered in a particular case. BCBSNM has full and final discretionaryauthority for their interpretation and application to the extent provided under any applicable plan documents.Providers are responsible for submission of accurate documentation of services performed. Providers are expected tosubmit claims for services rendered using valid code combinations from Health Insurance Portability and AccountabilityAct (“HIPAA”) approved code sets. Claims should be coded appropriately according to industry standard coding guidelinesincluding, but not limited to: Uniform Billing (“UB”) Editor, American Medical Association (“AMA”), Current ProceduralTerminology (“CPT ”), CPT Assistant, Healthcare Common Procedure Coding System (“HCPCS”), ICD-10 CM and PCS,National Drug Codes (“NDC”), Diagnosis Related Group (“DRG”) guidelines, Centers for Medicare and Medicaid Services(“CMS”) National Correct Coding Initiative (“NCCI”) Policy Manual, CCI table edits and other CMS guidelines.Claims are subject to the code edit protocols for services/procedures billed. Claim submissions are subject to claim reviewincluding but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical paymentand coding policies as well as coding software logic. Upon request, the provider is urged to submit any additionaldocumentation.Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)Policy Number: CPCP028Version: 2.0Medical Policy Review Committee Approval Date: Jan. 10, 2022Effective Date: April 15, 2022DescriptionThe purpose of this policy is to outline services (procedures codes or categories of codes) that are not reimbursablebecause they are explicitly determined, as indicated in the Coverage Statement of the Medical Policy, to beexperimental/investigational/or unproven and do not require clinical review to determine coverage. The following list ofcodes includes CPT Category I codes, HCPCS and CPT Category III codes (the temporary code set for emerging technology,services, procedures, and service paradigms) which will be denied as non-reimbursable when submitted on a claim.Reimbursement Information:The following list of procedure codes identifies the services that are not reimbursable based on the member’s plandocuments. This list may not be all inclusive.

CPT/HCPCS 591065911119111291132911339213292145CRYOTHERAPY OF SKINNDL INSJ W O NJX 1 OR 2 MUSCNDL INSJ W O NJX 3 MUSCCPTR-ASST DIR MS PXPRESCRL FUSE W/ INSTR L5-S1HI ENRGY ESWT PLANTAR FASCIARPR NSL VLV COLLAPSE W/IMPLTENDOVENOUS MCHNCHEM 1ST VEINENDOVENOUS MCHNCHEM ADD ONSUBMUCOSAL ABLTJ TONGUE RF 1 SITEESOPH OPTICAL ENDOMICROSCOPYEGD OPTICAL ENDOMICROSCOPYREPAIR ANORECTAL FIST W/PLUGTRANSURETHRAL RF TREATMENTINTRACRANIAL ANGIOPLASTYCOLLAGEN CROSSLINKSASSAY OF LIPOPROTEIN(A)ASSAY LIPOPROTEIN PLA2LIPOPROTEIN BLD HR FRACTIONLIPOPROTEIN BLD QUAN PARTLIPOPRTN DIR MEAS SD LDL CHLASSAY OF OSTEOCALCINEXHALED BREATH CONDENSATEEVAL AMNIOTIC FLUID PROTEINTHROMBOXANE URINEALLERGEN SPECIFIC IGGLEUKOCYTE HISTAMINE RELEASEOPTICAL ENDOMICROSCPY INTERPBREATH HYDROGEN METHANE TESTESOPHAGEAL CAPSULE ENDOSCOPYGI WIRELESS CAPSULE MEASUREELECTROGASTROGRAPHYELECTROGASTROGRAPHY W/TESTCMPTR OPHTH DX IMG ANT SEGMTCORNEAL HYSTERESIS /202009/01/202012/01/20202

CPT/HCPCS L FUNCTION STUDIESVEMP TEST I&R CERVICALVEMP TEST I&R OCULARVEMP TST I&R CERVICAL&OCULARCDP SOT 6 COND W I RCDP SOT 6 COND W I R MCT ADTART PRESSURE WAVEFORM ANALYSBIS XTRACELL FLUID ANALYSISTEMPERATURE GRADIENT STUDIESPATIENT RECORDED SPIROMETRYPATIENT RECORDED SPIROMETRYREVIEW PATIENT SPIROMETRYEYE ALLERGY TESTSDIRECT NASAL MUCOUS MEMBRANE TESTSMOTOR &/ SENS NRVE CNDJ TESTDIATHERMY EG MICROWAVELOW FREQUENCY NON-THERMAL USLPOPRTN BLD W/5 MAJ CLASSESBONE SRGRY CMPTR FLUOR IMAGEBONE SRGRY CMPTR CT/MRI IMAGAI SLE IGG IGM ALYS 80 BMRKNEURO AUTISM 32 AMINES ALGPAMG-1 IA CERVICO-VAG FLUIDPROSTH RETINA RECEIVE GENEXTRACORP SHOCKWV TX HI ENRGEXTRACORP SHOCKWV TX ANESTHTOUCH QUANT SENSORY TESTGASTRIC EMPTYING SERIAL COLLECTIONVIBRATE QUANT SENSORY TESTCOOL QUANT SENSORY TESTHEAT QUANT SENSORY TESTNOS QUANT SENSORY TESTRBC MEMBRANES FATTY ACIDSNEURO AUSTM MEAS 6 C METABLTOCULAR BLOOD FLOW MEASUREPOSTERIOR VERTEBRAL JOINT S ARTHROCLEAR EYELID GLAND 1/20203

CPT/HCPCS EMENT OF A POSTERIOR INTRAFACETPLMT POST FACET IMPLT THORPLACEMENT OF A POSTERIOR INTRAFACETPLACEMENT OF A POSTERIOR INTRAFACETNJX PLATELET PLASMAIM B1 MRW CEL THER CMPLIM B1 MRW CEL THER XCL HRVSTIM B1 MRW CEL THER HRVST ONLTEMPRTEAR FILM IMG UNI/BI W/I&RINSERTION OF SINUS TARSI IMPLANTTRNSCTH RENAL SYMP DENRV UNLTRNSCTH RENAL SYMP DENRV BILINS BONE DEVICE FOR RSARSA SPINE EXAMRSA UPPER EXTR EXAMRSA LOWER EXTR EXAMGASTROINTESTINAL TRACT IMAGING INTBIA WHOLE BODYVISUAL FIELD ASSESSMENT WITH CONCUVISUAL FIELD ASSESSMENT WITH CONCUINTRAOP KINETIC BALNCE SENSRERCP W/OPTICAL ENDOMICROSCPYASSAY SECRETORY TYPE II PLA2INSJ/RPLC NSTIM APNEA COMPLINSJ/RPLC NSTIM APNEA SEN LDINSJ/RPLC NSTIM APNEA STM LDINSJ/RPLC NSTIM APNEA PLS GNRMVL NSTIM APNEA PLS GENRMVL NSTIM APNEA SEN LDRMVL NSTIM APNEA STIMJ LDRMVL/RPLC NSTIM APNEA PLS GNREPOS NSTIM APNEA STIMJ LDREPOS NSTIM APNEA SENSING LDINTERRO EVAL NPGS APNEAPRGRMG EVAL NPGS APNEA 1 SESPRGRMG EVAL NPGS APNEA /20224

CPT/HCPCS IAL PLACEMENT OF A DRUG ELUTINGSBSQT PLMT DRUG ELUT OC INSVISUAL EP TEST FOR GLAUCOMASUPCHRDL NJX RX W/O SUPPLYPRGRMG IO RTA ELTRD RAREPRGRMG IO RTA ELTRD RAOCT MID EAR I R UNILATERALOPTICAL COHERENCE TOMOGRAPHY OCTNEAR INFRARED SPECTROSCOPY STUDIESCYSTO F URTL STRIX STENOSISNEAR IFR 2IMG MIBMN GLND I&RPLS ECHO US B1 DNS MEAS TIBPATTERN ERG W/I&RREMOVAL AND REINSERTION OF SINUS TAESW INTEG WND HLG 1ST WNDESW INTEG WND HLG EA ADDLCONT REC MVMT DO 6 10 DAYSCONT REC MVMT DO SETUP TRAINCONT REC MVMT DO REPRT CNFIGCONT REC MVMT DO DL W I RTRANSPERINEAL PERIURETHRAL BALLOONTPRNL BALO CNTNC DEV UNITPRNL BALO CNTNC DEV RMVL EATPRNL BALO CNTNC DEV ADJMTEVACUATION OF MEIBOMIAN GLANDS USIAUTOL CELL IMPLT ADPS HRVGAUTOL CELL IMPLT ADPS NJXTRANSDERMAL GFR MEARUSREMENTSTRANSDERMAL GFR MONITORINGEYE MVMT ALYS W/O CALBRJ I&REVASC VEN ARTLZ TIBL/PRNL VNTRABECULOSTOMY INTERNO LASERTRABECULOSTOMY INT LSR W/SCPAUTO QUANTIFICATION C PLAQUEAUTO QUAN C PLAQ DATA PREPAUTO QUAN C PLAQ CPTR ALYSAUTO QUAN C PLAQ 02101/01/202101/01/202101/01/202101/01/20215

CPT/HCPCS 0C9363C9364C9745C9749C9768C9771C9772C9773C9774PERQ NJX ALGC FLUOR LMBR 1STPERQ NJX ALGC FLUOR LMBR EAPERQ NJX ALGC CT LMBR 1STPERQ NJX ALGC CT LMBR EATC VIS LIT HYPERSPECTRAL IMGPERQ TCAT US ABLTJ NRV P-ARTWRLS SKN SNR ANISOTROPY MEASInnovamatrix ac, per sq cmMirragen adv wnd mat per sqXcellistem, per sq cmMicrolyte matrix, per sq cmNovosorb synpath per sq cmRestrata, per sq cmTheragenesis, per sq cmSymphony, per sq cmApis, per square centimeterTOPICAL HYPERBACI OXYGEN CHAMBER DINFRARED HT SYS REPLCMNT PADWOUND WARMING WOUND COVERINVERSION EVERSION COR DEVICHemostatic agent, gi, topicGEN, NEURO, TRANS SEN/STIMRETINAL PROSTH INT EXT COMPRETINAL PROSTH ADD ONACELLULAR PERICARDIAL TISSUE MATRIXTENOGLIDE TENDON PROT CM2DERMAL SUBSTITUTE NATIVE NON DENADERMAL SUBSTITUTE NATIVE NON DENAIntegra Meshed Bil Wound MatPORCINE IMPLANT PERMACOLNASAL ENDO EUSTACHIAN TUBEREPAIR NASAL STENOSIS W IMPEndo us-guide hep porto gradNsl/sins cryo post nasal tisREVASC LITHOTRIP TIBI/PERONEREVASC LITHOTR-STENT TIB/PERREVASC LITHOTR-ATHER 15/202108/15/20216

CPT/HCPCS 9G0428G0460G0465G9147K1002K1004K1007K1009REVASC LITH-STEN-ATH TIB/PERESOPHAG MUCOSAL INTEG ADD-ONINFRARED HEATING PAD SYSTEMWOUND WARMING DEVICEWARMING CARD FOR NWTELECTRONIC SPIROMETERPNEUMATIC COMPRESSION DEVICENON-IMPLANT PELV FLR E-STIMTRANS ELEC JT STIM DEV SYSFUNCTIONAL NEUROMUSCULARSTIMFUNCTIONAL NEUROMUSCULARSTIMELECTRIC WOUND TREATMENT DEVAMBULATORY TRACTION DEVICETRACT FRAME ATTACH HEADBOARDCERVICAL PNEUM TRAC EQUIPTRACTION STAND FREE STANDINGCERVICAL TRACTION EQUIPMENTCERVIC COLLAR W AIR BLADDERSTRACT EQUIP CERVICAL TRACTTRACTION FRAME ATTACH PELVICCPM DEVICE OTHER THAN KNEECERVICAL HEAD HARNESS/HALTERPELVIC BELT/HARNESS/BOOTCURRENT PERCEP THRESHOLD TSTELEC STIM UNATTEND FOR PRESSELECT STIM WOUND CARE NOT PDELECTROMAGNETIC THERAPY ONCELECTROMAGNTIC TX FOR ULCERSCOLLAGEN MENISCUS IMPLANT PROCEDUREAUTOLOGOUS PRP FOR ULCERSAUTOLOG PRP DIAB WOUND ULCEROUTPATIENT INTRAVENOUS INSULINTREATMENTCRANIAL ELECTROTHERAPY STIMULATIONLO FREQ US DIATHERMY DEVICEBil hkaf pc s/d micro sensorSpeech volume modulation 2012/01/202012/01/202003/01/202103/01/20217

CPT/HCPCS 6Q4137Q4138Q4139Q4140Q4141Q4142Q4143Q4145Q4146Ext up limb tremor stim wrisMonthly supp use with k1018Trans elec nerv periph nervNon pneum comp control calNon pneum compress full armINJECTABLE BULKING AGENT DEXTRANOMARG II EXT COM SUP ACC MISCPLAELET RICH PLASMA UNITOasis burn matrixIntegra BMWDPrimatrixGammagraftCymetra injectableGraftjacket xpressAlloskinHyalomatrixMatristem micromatrixTheraskinDermacell, awm, porous sq cmALLOSKINOASIS ULTRA TRI-LAYER WOUND DSTRATTICE TMhMatrixMediskinEZdermAMNIOEXCEL BIODEXCEL 1SQ CMBIODFENCE DRYFLEX PER SQUARE CENTIMAMNIOMATRIX OR BIODMATRIX, INJECTABBIODFENSE, PER SQUARE CENTIMETERAlloskin ac, 1 cmXcm biologic tiss matrix 1cmRepriza, 1cmEPIFIX, INJECTABLE, 1 MGTensix, 0218

CPT/HCPCS itect ecm px fx 1 sq cmNEOX 1K PER SQUARE CENTIMETERExcellagen, 0.1 ccALLOWRAP DS OR DRY 1 SQ CMDermapure 1 square cmDERMAVEST AND PLURIVEST, PER SQUARENEOXFLO OR CLARIXFLO 1 MGNEOX 100 1 SQUARE CMREVITALON 1 SQUARE CMKerecis omega3, per sq cmAFFINITY1 SQUARE CMNUSHIELD 1 SQUARE CMBio-connekt per square cmAMNIOPRO FLOW, BIOSKIN FLOW, BIORENAMNIOPRO, BIOSKIN, BIORENEW, WOUNDEHelicoll, per square cmKeramatrix, kerasorb sq cmCytal, per square centimeterTruskin, per sq centimeterARTACENT WOUND, PER SQUARE CENTIMETCYGNUS, PER SQUARE CENTIMETERINTERFYL, 1 MGPALINGEN OR PALINGEN XPLUS PER SQUPALINGEN OR PROMATRX 0 36 MG PER 0MicrodermNEOPATCH OR THERION, PER SQUARE CENFLOWERAMNIOFLO, 0.1 CCFLOWERAMNIOPATCH, PER SQUARE CENTIMFlowerderm, per sq cmREVITA, PER SQUARE CENTIMETERAMNIO WOUND, PER SQUARE CENTIMETERTranscyte, per sq centimeterSURGIGRAFT PER SQUARE CENTIMETERCELLESTA OR CELLESTA DUO, PER SQUARCELLESTA FLOWABLE AMNION (25 MG PERAMNIOARMOR PER SQUARE CENTIMETERARTACENT AC 1 2012/01/202012/01/202012/01/202012/01/20209

CPT/HCPCS CENT AC PER SQUARE CENTIMETERRESTORIGIN PER SQUARE CENTIMETERRESTORIGIN 1 CCColl-e-derm 1 sq cmNOVACHOR PER SQUARE CENTIMETERPuraply 1 sq cmPuraply am 1 sq cmPURAPLY XT PER SQUARE CENTIMETERGENESIS AMNIOTIC MEMBRANE PER SQUACygnus matrix, per sq cmSkin te 1 sq cmMATRION PER SQUARE CENTIMETERKeroxx (2.5g/cc), 1ccDerma-gide, 1 sq cmXWRAP PER SQUARE CENTIMETERMEMBRANE GRAFT OR MEMBRANE WRAP, PEFLUID FLOW OR FLUID GF, 1 CCNOVAFIX, PER SQUARE CENITMETERSURGRAFT, PER SQUARE CENTIMETERAXOLOTL GRAFT OR AXOLOTL DUALGRAFT,AMNION BIO OR AXOBIOMEMBRANE, PER SALLOGEN, PER CCASCENT, 0.5 MGCELLESTA CORD, PER SQUARE CENTIMETEAXOLOTL AMBIENT OR AXOLOTL CRYO, 0.ARTACENT CORD, PER SQUARE CENTIMETEWOUNDFIX, BIOWOUND, WOUNDFIX PLUS,SURGICORD, PER SQUARE CENTIMETERSURGIGRAFT-DUAL, PER SQUARE CENTIMEBellacell hd, surederm sq cmAMNIOWRAP2, PER SQUARE CENTIMETERProgenamatrix, per sq cmAMNIOCORE, PER SQUARE CENTIMETERBIONEXTPATCH, PER SQUARE CENTIMETERCOGENEX AMNIOTIC MEMBRANE, PER SQUACOGENEX FLOWABLE AMNION, PER 0.5 CCCORPLEX P, PER 2012/01/202012/01/202012/01/202012/01/202010