CommercialCoverageHigh impact
Experimental-Investigational Services
BCBS Arizona·AZ·Medical Policy
Effective date
Nov 1, 2026
We identified it
Oct 1, 2026
Summary
Blue Cross Blue Shield of Arizona has issued a new Evidence-Based Criteria policy (effective 11/01/26) that classifies 62 specific CPT and HCPCS codes as experimental or investigational services and therefore non-covered. This policy applies broadly across multiple specialties and requires billing teams to deny claims for these codes unless members have explicit coverage for experimental services in their benefit plans.
Action Required
By November 1, 2026: Billing team must update billing system edits and claim processing rules to flag all 62 listed CPT and HCPCS codes as experimental/investigational services for BCBSAZ Arizona members. Configure system to automatically deny claims for these codes unless prior authorization has been obtained or member has explicit experimental/investigational coverage. Update denial templates to reference policy O1213 and inform patients and providers that services meet one or more of the five experimental criteria (lack of FDA approval, insufficient scientific evidence, insufficient evidence of health outcome improvement, insufficient evidence vs. established alternatives, or insufficient evidence outside investigational setting). Notify in-house providers and contracted providers of code restrictions. Claims submitted for these codes without exception documentation will be denied. Create internal tracking to monitor for exceptions requests and ensure Medical Director review per policy guidance that 'providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines.'