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CommercialCoverageMedium impact

Investigational Services (BSC9.01)

Blue Shield of California·CA · Orthopedics, Neurosurgery, Cardiology +6 more·Medical Policy
Effective date
Sep 1, 2026
We identified it
Sep 1, 2026
Days to comply

Summary

Blue Shield of California has updated its Investigational Services policy (BSC9.01) effective September 1, 2026, establishing criteria for denying coverage of healthcare services lacking complete testing, established efficacy/safety, and wide usage. The policy provides an expanded list of specific CPT and HCPCS codes classified as investigational, including new codes effective January 1, 2026. Billing teams must identify claims using these codes and apply non-coverage determinations based on investigational status.

Action Required

Action needed
By August 15, 2026: Billing team must update claims processing system and billing software to recognize all listed CPT and HCPCS codes as non-covered investigational services under policy BSC9.01. Configure system to automatically deny claims for codes 22526, 22527, 22586, 36837, 84112, 0219T, 0312U, 0394T, 0395T, 0623T, 0649T, 0673T, 0686T, 0735T, 0753T, 0988T, 0989T, 0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, and 0997T with denial reason 'Investigational Service - Not Covered.' Update provider encounter forms and superbills to flag these codes as non-billable to Blue Shield of California. Implement notification process to alert providers and patients that these services are investigational and not covered; claims submitted without prior member notification may result in patient balance responsibility. Train front desk and authorization staff that these codes do not require clinical review—they are denied based on investigational classification per policy. Note: Code 0394T effective 1/1/2026 is deleted and should be removed from system; codes 0988T, 0989T, 0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, and 0997T become investigational effective 1/1/2026. Verify member contracts for any exceptions that override this policy (e.g., FDA-approved services may require medical necessity determination per Health and Safety Code 1363.32).

Affected Billing Codes

22526
22527
22586
36837
84112