Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Experimental/Investigational Services
Policy #:MA00.005u

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy identifies services not found in a specific Company policy that are determined to be experimental/investigational and, therefore, not covered.

Lists of services in attachments A, B, and C may not be all-inclusive. Services will be added or deleted from the lists as changes in coverage position occur or if the experimental/investigational status of a service changes.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

For services for which there is no Medicare coverage determination, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, services listed in Attachments A, B, and C are not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the services are considered experimental/investigational and, therefore, not covered.
Description

Experimental and investigational services (e.g., devices, drugs, procedures, supplies, technologies, treatments) are services whose safety and/or effectiveness are not known, or services that are used in a way that departs from generally accepted standards of practice in the medical community.

The term experimental/investigational is used to describe services that address a drug, biological product, device, medical treatment, diagnostic test, or procedure that meets any of the following:
  • Is the subject of ongoing Clinical Trials
  • Is the research, experimental study, or investigational arm of an ongoing Clinical Trial(s) or is otherwise under a systematic, intensive investigation to determine its maximum tolerated dose, its toxicity, its safety, its effectiveness, or its effectiveness as compared with a standard means of treatment or diagnosis
  • Is not of proven benefit for the particular diagnosis or treatment of the covered individual's particular condition
  • Is not generally recognized by the medical community, as clearly demonstrated by Reliable Evidence, as effective and appropriate for the diagnosis or treatment of the covered individual's particular condition
  • Is generally recognized by the medical community, based on Reliable Evidence, as a diagnostic or treatment intervention for which additional study, regarding its safety and effectiveness for the diagnosis or treatment of the covered individual's particular condition, is recommended
    References

    Novitas Solutions, Inc. Local Coverage Determination (L35094). Services That Are Not Reasonable and Necessary. Original: 10/01/2015. (Revised: 09/12/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35094&ver=224&Date=03%2f24%2f2020&SearchType=Advanced&DocID=l35094&bc=KAAAAAgAAAAA&. Accessed March 24, 2020.


    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachments A, B and C


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachments A, B and C


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Experimental/Investigational Services
Description: Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.

Attachment B: Experimental/Investigational Services
Description: Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.

Attachment C: Experimental/Investigational Services
Description: Experimental/Investigational services with a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code, that are reported for other services.







Policy History

Revisions from MA00.005u
04/01/2020The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 0165U, 0167U

The following procedures are represented by unlisted code 27299 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Injection of PRO-DENSE™
  • PRO-DENSE™
  • Bone Graft Substitute
  • Injectable Regenerative Graft

The following procedures are represented by unlisted code 37799 (Unlisted procedure, vascular surgery) and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • SENTINEL™ Cerebral Protection
  • Filterwire EZ Embolic Protection System
  • Embolic Protection Device (EPD)
  • Distal Occlusion Device
  • Proximal Occlusion Device

Revisions from MA00.005t
01/27/2020The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 31647, 31651

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is communicated through Medicare Advantage Policy MA11.004 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH): 53854
________________________________________________________________

Note: On 01/03/2020, this policy was updated with the following coding changes effective 01/01/2020.

The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 46948, 64454, 64624, 92549, 0563T, 0567T, 0568T, 0569T, 0570T, 0571T, 0572T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0581T, 0582T, 0583T, 0587T, 0589T, 0590T, 0139U

The following CPT code has been termed and removed from Attachment A and is replaced by the following unlisted code in Attachment B:
    REMOVED: 0205T
    REPLACED WITH: 93799

The following CPT code has been termed and removed from Attachment A and is replaced by the following unlisted code in Attachment B:
    REMOVED: 0206T
    REPLACED WITH: 93799

The following CPT code has been termed and removed from Attachment A of this policy: 0254T

The following CPT code has been termed and removed from Attachment A and is replaced by the following unlisted code in Attachment B:
    REMOVED: 0341T
    REPLACED WITH: 92499

The following CPT code has been termed and removed from Attachment A and is replaced by the following unlisted code in Attachment B:
    REMOVED: 0377T
    REPLACED WITH: 46999

The following CPT code has been termed and removed from Attachment A and is replaced by the following unlisted code in Attachment B:
    REMOVED: 0380T
    REPLACED WITH: 92499

The following CPT code has been termed and removed from Attachment A and is replaced by the following CPT code in Attachment A:
    REMOVED: 0399T
    REPLACED WITH: 93356

The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 0554T, 0555T, 0556T, 0557T, 0558T

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is communicated in Medicare Advantage Policy MA06.017 Molecular Diagnostics: 0124U, 0125U, 0126U

The following CPT narratives have been revised in Attachment A of this policy: 64405, 92548

The following HCPCS codes are considered Experimental/Investigational and have been added to Attachment A of this policy: C1734, C1824, C1839, C1982, K1001, K1004, L2006

The use of a Magnetically Controlled Growing Rod is represented by unlisted code 22899 and is considered Experimental/Investigational, and has been added to Attachment B of this policy.
The following procedures are represented by unlisted code 43999 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Gastric Per Oral Endoscopic Myotomy (G-POEM)
  • Per Oral Pyloromyotomy (POP)
The use of iCAD VividLook is represented by unlisted code 76498 and is considered Experimental/Investigational, and has been added to Attachment B of this policy.

The following procedures, represented by unlisted codes 22899 and 64999, have been removed from Attachment B of this policy because their coverage position is communicated in Medicare Advantage Policy MA11.097 Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis:
  • Image guided minimally invasive lumbar decompression for nervous system
  • Vertos MILD

Revisions from MA00.005s
10/01/2019The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0105U, 0106U, 0107U, 0108U, 0119U, 0121U, 0122U, 0123U, 0124U, 0125U, 0126U, 0127U, 0128U

The following HCPCS code is considered Experimental/Investigational and has been added to Attachment A of this policy: J9285

The following HCPCS codes are considered Medically Necessary and have been removed from Attachment A of this policy: A4555, E0766

The use of an Erector Spinae Plane (ESP) Block is represented by unlisted code 64999 and is considered Experimental/Investigational, and has been added to Attachment B of this policy:
  • Erector Spinae Plane (ESP) Block
  • Ultrasound-Guided Erector Spinae Plane Block

The following CPT codes have been removed from Attachment A of this policy because they are considered Medically Necessary: 31626, 31627

Revisions from MA00.005r
07/01/2019The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0543T, 0544T, 0545T, 0547T, 0549T, 0553T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T, 0560T, 0561T, 0562T, 0091U, 0092U, 0095U

The following HCPCS code is considered Experimental/Investigational and has been added to Attachment A of this policy: C9756

The following HCPCS code has been termed and removed from Attachment A and is replaced by the following CPT code in Attachment A:
    REMOVED: C9746
    REPLACED WITH: 0548T

The following NOC code has been removed from Attachment B of this policy and is replaced by the following CPT code in Attachment A:
    REMOVED: 19499 (used to report Radiofrequency Spectroscopy, MarginProbe®, Handheld Radiofrequency Spectroscopy)
    REPLACED WITH: 0546T

The following CPT code has been removed from Attachment A of this policy because it is considered Medically Necessary: 52010

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is communicated in Medicare Advantage Policy MA07.023 Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic): 0397T

Revisions from MA00.005q
01/01/2019The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 33289, 53854, 64632, 64640, 83722, 93264, 0511T, 0512T, 0513T, 0514T, 0515T, 0516T, 0517T, 0519T, 0520T, 0521T, 0522T, 0523T, 0525T, 0526T, 0527T, 0528T, 0529T, 0533T, 0534T, 0535T, 0536T, 0541T, 0542T, 0083U

The following CPT codes have been termed and have been removed from Attachment A of this policy: 0195T, 0196T, 0337T, 0346T, 0359T, 0360T, 0361T, 0363T, 0364T, 0365T, 0366T,0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0374T

The following CPT code has been removed from Attachment A of this policy because it is considered Medically Necessary: 83993

The following CPT narratives have been revised in Attachment A of this policy: 0335T, 0362T, 0373T

The following HCPCS codes are considered Experimental/Investigational and have been added to Attachment A of this policy: A4563, C9751, C9752, C9753, L8608, L8701, L8702

The following HCPCS codes have been termed and have been removed from Attachment A of this policy: C9741, C9748, C9750

The following HCPCS code has been removed from Attachment A of this policy because it is considered Medically Necessary: A9584

The following HCPCS code has been removed from Attachment A of this policy because its coverage position is now communicated in MA08.003 Enteral Nutritional Therapy: Q9994

The following service is represented by unlisted code 19499 and is considered Experimental/Investigational, and has been added to Attachment B of this policy:
  • Use of the Savi Scout Surgical Guidance System

The following services are represented by unlisted code 64999 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Spenopalatine ganglion (SPG) block
  • Use of the Tx360® Nasal Applicator
  • Use of the SphenoCath®

The following services are represented by unlisted code E1399 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Freespira®
  • Savi Scout Surgical Guidance System
  • Tx360® Nasal Applicator
  • SphenoCath®

The following services are represented by unlisted code 28899 and have been removed from Attachment B of this policy because they are now reported with CPT codes 0512T and 0513T:
  • Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound
  • Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure)

The following service represented by CPT codes 90875, 90876, and 90901 is considered Experimental/Investigational, and has been added to Attachment C of this policy:
  • Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira®)

Revisions from MA00.005p
10/01/2018The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0062U, 0063U, 0066U

The following HCPCS code is considered Experimental/Investigational and has been added to Attachment A of this policy: C9750

The following services are represented by unlisted code 19499 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
    • Radiofrequency Spectroscopy
    • MarginProbe®
    • Handheld Radiofrequency Spectroscopy

The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 0159T, 55874

The following HCPCS code is considered Medically Necessary and has been removed from Attachment A of this policy: S2107

Revisions from MA00.005o
07/23/2018The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is communicated in Medicare Advantage Policy MA07.026 Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring: 0497T, 0498T

The following diagnostic tests are considered Experimental/Investigational and have been added to Attachment B of this policy:
  • WATS3D® by CDx® Diagnostics™
  • OralCDx® Brush Biopsy (or Brush Test®) by CDx® Diagnostics™
  • EndoCDx® TNE: Transnasal Esophagoscopy (or EndoCDx® brush biopsy) by CDx® Diagnostics™
  • EndoCDx® LP - Laryngeal (or Transepithelial Laryngeal Brush Biopsy) by CDx® Diagnostics™

Revisions from MA00.005n
07/01/2018The following CPT codes have been added to Attachment A of this policy: 0333T, 0506T, 0507T, 0052U, 0061U

Code B9998, used to report Relizorb, has been deleted from Attachment B of this policy, and replaced with HCPCS code Q9994 in Attachment A.

Revisions from MA00.005m
04/01/2018The following CPT codes have been added to Attachment A of this policy: 62280, 62281, 62282, 62292

Note: On 03/29/2018 the policy in Notification was updated with medical codes effective 04/01/2018.

The following CPT codes are considered Experimental/Investigational, and have been added to Attachment A of this policy:
  • 0497T
  • 0498T
  • 0043U
  • 0044U

The following HCPCS code is considered Experimental/Investigational, and has been added to Attachment A of this policy:
  • C9749

The following CPT code has been removed from Attachment A of this policy:
  • 27279

Revisions from MA00.005l
01/01/2018This version of the policy will become effective 01/01/2018.

This policy has been identified for the CPT / HCPCS code update.

The following CPT codes have been added to Attachment A of this policy: 64912, 64913, 0483T, 0484T, 0485T, 0486T, 0487T, 0489T, 0490T, 0491T, 0492T, 0493T, 0499T, 0024U, 0025U

The following HCPCS code has been added to Attachment A of this policy: C9748

The following CPT code has been removed from Attachment A of this policy and is replaced by the following CPT code:
    REMOVED: 0438T
    REPLACED WITH: 55874

The following CPT codes have been removed from Attachment A of this policy and are replaced by the following NOC code (in Attachment B):
    REMOVED: 0178T, 0179T, 0180T
    REPLACED WITH: 93799

The following CPT codes have been removed from Attachment A of this policy and are replaced by the following NOC code (in Attachment B):
    REMOVED: 0299T, 0300T
    REPLACED WITH: 28899

The following CPT code has been removed from Attachment A of this policy and is replaced by the following NOC code (in Attachment B):
    REMOVED: 0301T
    REPLACED WITH: 19499

The following CPT code has been removed from Attachment A of this policy and is replaced by the following NOC code (in Attachment B):
    REMOVED: 0309T
    REPLACED WITH: 22899

The following CPT code has been removed from Attachment A of this policy and is replaced by the following NOC code (in Attachment B):
    REMOVED: 0310T
    REPLACED WITH: 64999

The following CPT codes have been termed and removed from Attachment A of this policy: 0255T, 0293T, 0294T, 0302T, 0303T, 0304T, 0305T, 0306T, 0307T

The following CPT narrative has been revised in Attachment A of this policy: 0254T

The following service is represented by unlisted code 43499 and is considered Experimental/Investigational, and has been added to Attachment B of this policy: Per-Oral Endoscopic Myotomy (POEM)

The following service is represented by unlisted codes 44799 and 45399 and is considered Experimental/Investigational, and has been added to Attachment B of this policy: Chromoendoscopy

The following service is represented by unlisted code 69799 and is considered Experimental/Investigational, and has been added to Attachment B of this policy: Balloon dilation of eustachian tube

The following services represented by CPT code 83516 are considered Experimental/Investigational, and have been added to Attachment C of this policy:
  • InflammaDry
  • Matrix Metalloproteinase-9 (MMP-9) when used as an inflammatory marker to detect dry eye disease

Revisions from MA00.005k
11/03/2017The following CPT codes have been removed from Attachment A of this policy: 0100T, 0387T, 0388T, 0389T, 0390T, 0391T.

Revisions from MA00.005j
07/18/2017The following CPT code has been removed from Attachment A of this policy and is now considered eligible: 55870.

The following CPT code is considered Experimental/Investigational, and has been added to Attachment A of this policy: 92548.

The following service, represented by unlisted code B9998, is considered Experimental/Investigational and has been added to Attachment B of this policy: Relizorb™.

Note: On 6/21/2017 the following 07/01/2017 codes were added to Attachment A: 0470T, 0471T, 0472T, 0473T, 0475T, 0476T, 0477T, 0478T, C9745, C9746.

Revisions from MA00.005i
03/01/2017The following CPT codes have been removed from Attachment A of this policy because their Medically Necessary coverage position is communicated in a separate Medicare Advantage policy: 43206, 43252

The following CPT codes have been removed from Attachment A of this policy because they are considered Medically Necessary: 0001M, 0002M, 0003M

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is communicated in a separate Medicare Advantage policy: 0071T, 0072T, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 0396T, 0406T, 0407T, 0421T

The following CPT codes have been termed, effective 01/01/2017, because these services are no longer in use and have been removed from Attachment A of this policy: 0287T, 0289T

The following CPT codes have been termed, effective 01/01/2017, and removed from Attachment A of this policy and are replaced in Attachment C by the following CPT codes:
    REMOVED: 0291T
    REPLACED WITH: 92978

    REMOVED: 0292T
    REPLACED WITH: 92979

The following CPT codes have been termed, effective 01/01/2017, and removed from Attachment C of this policy and are replaced in Attachment C by the following CPT codes:
    REMOVED: 35460, 35476, 75978
    REPLACED WITH: 36902, 36905, 36907, 37246, 37247, 37248, 37249

The following CPT codes have been termed, effective 01/01/2017, and removed from Attachment A of this policy, however these services remain as Experimental/Investigational and will be replaced with a Not Otherwise Classified (NOC) code and added to Attachment B:
    REMOVED: 0169T, 0282T, 0283T, 0284T, 0285T
    REPLACED WITH: NOC Code 64999

    REMOVED: 0286T
    REPLACED WITH: NOC Code 76499

    REMOVED: 0288T
    REPLACED WITH: NOC Code 46999

The following CPT narratives have been revised in Attachment A of this policy: 0419T, 0420T, 0443T

Revisions from MA00.005h
01/01/2017The following codes currently eligible will now be considered experimental/investigational and will be added to the Experimental/Investigational policy effective 01/01/2017.
  • 0159T
  • A9584
  • 62291
  • 77605

The following codes are being included in this policy update, with the effective date of 11/1/2016.
  • 86357
  • 86677

The following HCPCS were removed from Attachment A:
  • C9739
  • C9740

Refer to the specific policy for coverage: #MA11.004d: Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH).

The following CPT codes have been added to this policy, as part of the January 1, 2017 code update:
  • 0446T, 0447T, 0448T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0464T, 0465T, 93590, 93591, 93592

The Company’s coverage position on Intestinal Rehabilitation has changed from Experimental/Investigational to Medically Necessary. Therefore, this service has been removed from this policy.

Revisions from MA00.005g
10/01/2016The following code currently eligible will now be considered experimental/investigational and will be added to this policy, effective 10/01/2016.
  • 0439T
  • 83993

The following codes are being removed from this policy. Please refer to the specific policy for the coverage position; Transtympanic Micropressure Device as a Treatment of Meniere Disease:
  • A4638 Replacement battery for patient-owned ear pulse generator, each
  • E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

Revisions from MA00.005f
07/01/2016The following CPT codes have been added to this policy, as part of the July 1, 2016 code update;
  • 0437T, 0438T, 0440T, 0441T, 0442T, 0443T, 0444T, 0445T


The following HCPCS code was deleted as part of the July 1, 2016 code update;
  • C9743 Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies)

Revisions from MA00.005e
01/01/2016This version of the policy will become effective January 1, 2016


THE FOLLOWING CODES BEING 
ADDED:

96931, 96932, 96933, 96934, 96935, 96936, 0396T, 0397T, 0399T, 0400T, 0401T, 0403T, 0404T, 0405T, 0406T, 0407T, 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0419T, 0420T, 0421T, 0422T, 0423T, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T.

THE FOLLOWING CODE IS BEING REVISED:

CODE 0358T

THE FOLLOWING CODE IS BEING DELETED AND REPLACED WITH A SPECIFIC CODE;

DELETE 0099T ; REPLACE WITH 65785 

DELETE 0311T; REPLACE WITH 93050

THE FOLLOWING CODES ARE BEING DELETED, HOWEVER THESE SERVICES REMAIN AS EXPERIMENTAL/INVESTIGATIONAL AND WILL BE REPLACED WITH A NOT OTHERWISE CLASSIFIED (NOC) CODE:

0103T; REPLACED WITH NOC CODE; 84999
0123T; REPLACED WITH NOC CODE; 66999
0223T; REPLACED WITH NOC CODE; 93799
0224T; REPLACED WITH NOC CODE; 93799
0225T; REPLACED WITH NOC CODE; 93799
0233T; REPLACED WITH NOC COCE; 88749
0240T; REPLACED WITH NOC CODE; 91299
0241T; REPLACED WITH NOC CODE; 91299
0243T; REPLACED WITH NOC CODE; 94799
0244T; REPLACED WITH NOC CODE; 94799

THE FOLLOWING CODES ARE BEING REMOVED FROM THIS POLICY, AS THE COVERAGE FOR THIS SERVICE IS NOW FOUND IN A SPECIFIC MEDICARE ADVANTAGE POLICY:

G0455 Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen

0281T

THE FOLLOWING CODE IS BEING REMOVED FROM THIS POLICY, AS MEDICARE IS REMOVING THIS CODE FROM THEIR NON-COVERAGE POLICY.
0336T 


THE FOLLOWING HCPCS CODES ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL, AND HAVE BEEN ADDED TO THIS POLICY:

C9743 Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies)

C1841 Retinal Prosthesis, includes all internal and external components

Revisions from MA00.005d
10/01/2015The notable differences in the updated version of this policy from that of the previous version are:

The following services have been determined to be Experimental/Investigational and have been added to this policy.
  • Injection, anesthetic agent, greater occipital nerve Code: 64405
  • Altered Auditory Feedback for Stuttering; Code: E1399
  • Powered Exoskeleton Devices for Lower Extremities, Code: N/A

On 09/16/2015 the following CPT codes were removed from Attachment A of this policy.
33270, 33271, 33272, 33273, 93260, 93261, 93644

These codes will be incorporated into a more specific policy on 10/01/2015.

Revisions from MA00.005c
07/01/2015The following services have been removed from this policy effective 7/1/2015. Please refer to the specific policy regarding this service: 33418, 33419

Revisions from MA00.005b
6/19/2015 The notable differences in the updated version of this policy from that of the previous version are:
  • The following HCPCS codes have been removed from this policy:

C9349, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159 and Q4160


Please refer to the specific policy Wound Care Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds for the coverage position of these codes.

Revisions from MA00.005a
4/10/2015This policy will become effective on 4/10/2015.

The notable differences in the updated version of this policy from that of the previous version are:

Attachment A MA00.005a (Experimental/Investigational)
  • The coverage position for the following CPT code has been changed from Medically Necessary to Experimental/Investigational, and has been added to this policy:
    83698
  • The following codes, already considered to be experimental services, are being added to this policy, because the specific policy on these topics is being archived: 0085T, 53860
  • The coverage position for the following CATEGORY III CPT Codes has been changed from Medically Necessary to Experimental/Investigational, and have been added to this policy: 0291T, 0292T


Attachment B MA00.005a (Experimental/Investigational)
    The following unlisted code 53899 is considered Experimental/Investigational when reported with the following services, and has been added to this policy, because the specific policy on this topic is being archived.
      Transvaginal or paraurethral radiofrequency bladder neck suspension as a treatment for urinary stress incontinence
  • The following unlisted codes 81599 and 84999 are considered Experimental/Investigational when reported with the following services, and have been added to this policy:
    Avise 2.0
    Avise SLE
    Avise SLE+
    Avise MTX
    Avise HCQ
    Avise SLE+CT 2.0
    Avise SLE Prognostic
    Avise Therapeutic Drug Monitoring

  • Removing an unlisted code or Not Otherwise Classified (NOC) code:

The following unlisted code, 99199, is considered Experimental/Investigational when reported with the following service. This NOC code representing topical oxygenation has been removed from this policy to reside in the specific policy MA07.011 Topical Oxygenation.

Revisions from MA00.005
01/01/2015New policy number MA00.005 issued as a result of the development of a separate book of Medicare Advantage policy. Policy's coverage position is based on Medicare's coverage position for a service. In absence of a Medicare coverage position, the Company position for that service is being applied. This policy was developed with current Medicare Advantage policy Style Guide language and formatting.

Note: on 12/23/2014 this Policy Notification was updated in accordance with the CPT/HCPCS coding updates effective 1/1/2015.

The following CPT / HCPCS codes have been added to this policy:

20983, 27279, 33270, 33271, 33272, 33273, 33418, 33419, 92145, 93260, 93261, 93644, 93895, 0377T, 0378T, 0379T, 0380T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0387T, 0388T, 0389T, 0390T, 0391T, C2624, C9349, C9735, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160.

The following CPT codes have been deleted from this policy:

61875, 0181T, 0199T, 0226T, 0227T, 0326T, 0327T, 0328T






Version Effective Date: 04/01/2020
Version Issued Date: 04/10/2020
Version Reissued Date: N/A