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CLAIM PAYMENT AND CODING POLICYIf 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/orplans, the provider contract will govern. “Plan documents” include, but are not limited to, Certificates of Health CareBenefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. BCBSTX may use reasonablediscretion interpreting and applying this policy to services being delivered in a particular case. BCBSTX has full and finaldiscretionary authority for their interpretation and application to the extent provided under any applicable plandocuments.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 claimreview including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinicalpayment and coding policies as well as coding software logic. Upon request, the provider is urged to submit anyadditional documentation.Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)Policy Number: CPCP028Version: 2.0Medical Policy Review Committee Approval Date: Jan. 28, 2021Effective Date: August 15, 2021 (Blue Cross and Blue Shield of Texas Only)DescriptionThe 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 listof codes includes CPT Category I codes, HCPCS and CPT Category III codes (the temporary code set for emergingtechnology, services, procedures, and service paradigms) which will be denied as non-reimbursable when submitted ona 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.1Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

CPT/HCPCS PY 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 DETERNASAL FUNCTION 01/202009/01/202012/01/202009/01/20202

CPT/HCPCS T0108T0109T0110T0111T0139U0198T0202T0207T0219TVEMP 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 W/HEATPLACEMENT OF A POSTERIOR 12/01/20203

CPT/HCPCS T0473T0485T0486T0493T0499T0507T0508T0509T0511TPLMT 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 PLA2INITIAL 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 204

CPT/HCPCS T0632T0639TA4575A4639A6000A9285C1052C1841C1842ESW 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 I&RPERQ 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 MEASTOPICAL HYPERBACI OXYGEN CHAMBER DINFRARED HT SYS REPLCMNT PADWOUND WARMING WOUND COVERINVERSION EVERSION COR DEVICHEMOSTATIC AGENT, GI, TOPICRETINAL PROSTH INT EXT COMPRETINAL PROSTH ADD 2012/01/202005/15/202112/01/202012/01/20205

CPT/HCPCS LULAR 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 TIB/PERREVASC 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 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 202009/01/202009/01/20206

CPT/HCPCS 4Q4125Q4126Q4127Q4130Q4134Q4135Q4136Q4137ELECT STIM WOUND CARE NOT PDELECTROMAGNETIC THERAPY ONCELECTROMAGNTIC TX FOR ULCERSCOLLAGEN MENISCUS IMPLANT PROCEDUREAUTOLOGOUS PRP FOR ULCERSOUTPATIENT INTRAVENOUS INSULINTREATMENTCRANIAL ELECTROTHERAPY STIMULATIONLO FREQ US DIATHERMY DEVICEBIL HKAF PC S/D MICRO SENSORSPEECH VOLUME MODULATION SYSEXT UP LIMB TREMOR STIM WRISMonthly supp use with k1018INJECTABLE 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 2105/15/202105/15/202112/01/20207

CPT/HCPCS FENCE DRYFLEX PER SQUARE CENTIMAMNIOMATRIX OR BIODMATRIX, INJECTABBIODFENSE, PER SQUARE CENTIMETERALLOSKIN AC, 1 CMXCM BIOLOGIC TISS MATRIX 1CMREPRIZA, 1CMEPIFIX, INJECTABLE, 1 MGTENSIX, 1CMARCHITECT 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 2112/01/202012/01/202012/01/202005/15/20218

CPT/HCPCS TA, 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 MGARTACENT 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 SQUASKIN 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 2012/01/202012/01/202012/01/202005/15/20219