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Experimental/Investigational Services
12.01.01bu

Policy

This policy addresses those specific services that are determined by the Company to be experimental/investigational based on the definition found in most of the Company's bene​fit contracts. The services that are listed in Attachments A, B, and C are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature.

The list of services in Attachments A, B, and C are not all-inclusive. Attachments A, B, and C do not list those services determined by the Company to be experimental/investigational that are contained in a separate medical policy. Additions and deletions will be made as changes occur or if the experimental/investigational status of a service changes. The services that are listed do not include services that have split-coverage decisions based on criteria.

The following is a summary of the general principles that form the basis for the Company’s determination that a service is experimental/investigational. For the purposes of this policy, experimental/investigational will be the preferred term and will be used throughout this document. This summary is provided for illustrative purposes only. Please consult the applicable health benefit plan contract for the specific definition of experimental/investigational.

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 criteria:
  • 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 person’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 person’s particular condition
  • Is generally recognized, based on reliable evidence, by the medical community, as a diagnostic or treatment intervention for which additional study regarding its safety and effectiveness for the diagnosis or treatment of the covered person’s particular condition is recommended
The term "reliable evidence" is used to describe peer-reviewed reports of clinical studies that have been designed according to accepted scientific standards such that potential biases are minimized to the fullest extent​, and generalizations may be made about safety and effectiveness of the technology outside of the research setting. Studies are to be published or accepted for publication in medical or scientific journals that meet nationally recognized requirements for scientific manuscripts and that are generally recognized by the relevant medical community as authoritative. Furthermore, evidence-based guidelines from respected professional organizations and governmental entities may be considered reliable evidence if generally accepted by the relevant medical community.

Guidelines

BENEFIT APPLICATION

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

Services that are experimental/investigational are a benefit contract exclusion for most plans of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

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

References

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)
See Attachments A, B, and C.
ICD - 10 Procedure Code Number(s)
N/A
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

Policy History

Revisions From 12.01.01bu:
07/01/2026


This version of the policy is retroactively effective to 07/01/2026.

The policy has been updated as follows:

​ADDITIONS

CPT CODES

The following CPT codes are new for 07/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: 0636U, 0637U, 0638U, 0639U, 0640U, 0654U, 0655U, 0656U, 1026T, 1027T, 1028T, 1029T, 1030T, 1031T, 1032T, 1033T, 1034T, 1035T, 1036T, 1037T, 1038T, 1039T, 1040T, 1041T, 1042T, 1050T, 1051T, 1052T, 1053T. 

HCPCS CODES

The following HCPCS codes are new for 07/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: C1609, C8014, G0577. 

UNLISTED CODES

The following service is Experimental/Investigational and has been added to Attachment B with unlisted codes 64999, A4649, C9399:

  • VersaWrap scar barrier membrane
  • Application of VersaWrap scar barrier membrane​

The following service is Experimental/Investigational and has been added to Attachment B with unlisted codes 64999, A4649, C9399:

  • Stravix Nerve Wrap
  • Application of Stravix Nerve Wrap​
REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because they are now considered eligible: 55880, 64466, 64467, 64468, 64469. 

HCPCS CODES

The following HCPCS code has been removed from Attachment A of this policy because it is now considered eligible: C1747. 

The following HCPCS codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 05.00.39 Ankle-Foot/Knee-Ankle-Foot Orthoses as Experimental/Investigational: L2006, L2221. 

TERMINATED

CPT CODES


The following CPT code has been terminated (effective 07/01/2026) and removed from Attachment A of this policy: 0577U. 


REVISIONS

CPT CODES


The following CPT code narratives (effective 07/01/2026) have been revised in Attachment A of this policy: 0522U, 0598U, 0882T, 0883T, C9809. ​





Revisions From 12.01.01bt:
04/01/2026


This version of the policy is retroactively effective to 04/01/2026.

The policy has been updated as follows:

​ADDITIONS

CPT CODES

The following CPT codes are new for 04/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: 0614U, 0615U. 

HCPCS CODES

The following HCPCS codes are new for 04/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: A4479, A8005, A8006, C1743, C8010, G0680, L2221.

The following HCPCS codes are Experimental/Investigational, and have been added to Attachment A of this policy because the NewsFLASH “Pemivibart (Pemgarda) for Pre-Exposure Prophylaxis for Coronavirus Disease 2019 (COVID-19) for Commercial Members” is being archived: M0224, Q0224.

UNLISTED CODES

The following services are Experimental/Investigational and have been added to Attachment B with unlisted code 20999:
  • ​Autologous tissue cell harvesting and application
  • Hematopoietic Tissue Cells Harvested and Applied
Remote monitoring rehabilitative systems (i.e., ROMTech PortableConnect and AccuAngle) are reported with unlisted code E1399 as currently there is no specific code. ROMTech PortableConnect and ROMTech AccuAngle are Experimental/Investigational and have been added to Attachment B with unlisted code E1399. 

REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 11.03.02 Bariatric Surgery as Experimental/Investigational: 43290, 43291, 43889, 0813T. 

The following CPT code has been removed from Attachment A of this policy because its coverage position is being communicated in Medical Policy 11.02.29 Renal Denervation for Uncontrolled Hypertension as Experimental/Investigational: 0935T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 11.17.06 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia as Experimental/Investigational: 51721, 55881, 55882. 

HCPCS CODES

The following HCPCS code has been removed from Attachment A of this policy because it is now considered eligible: C9756. 


Revisions From 12.01.01bs:
01/01/2026


This version of the policy will become retroactively effective 01/01/2026.

​ADDITIONS

CPT CODES

The following CPT codes are new for 01/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: 37262, 37279, 43889, 47384, 55868, 55877, 63032, 64728, 87627, 0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, 0999T, 1000T, 1001T, 1002T, 1003T, 1004T, 1005T, 1006T, 1007T, 1008T, 1009T, 1010T, 1012T, 1019T, 1020T, 1021T, 0601U, 0604U, 0606U, 0609U, 0610U.

HCPCS CODES

The following HCPCS codes are new for 01/01/2026, are Experimental/Investigational, and have been added to Attachment A of this policy: C1607, C1608, C7571, C9810, C9815, C9816, C9817, G0571.

The following HCPCS codes are Experimental/Investigational, and have been added to Attachment A of this policy because Medical Policy 07.00.09 Topical Oxygenation is being archived: A4575, E0446.

UNLISTED CODES

Unlisted code 99199 is used to represent Topical Oxygenation when reported as a professional service. Topical Oxygenation is Experimental/Investigational, and this unlisted code is being added to Attachment B of this policy because Medical Policy 07.00.09 Topical Oxygenation is being archived.

​REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 07.03.28 Laser Interstitial Thermal Therapy (LITT) as Medically Necessary: 61736, 61737.

The following CPT codes have been removed from Attachment A of this policy and will be homeless and eligible until a separate Medical Policy is developed: 98975, 98976, 98978, 98980, 98981.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 11.02.29 Renal Denervation for Uncontrolled Hypertension as Experimental/Investigational: 0338T, 0339T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 05.00.77 Implantable Cardioverter Defibrillators as Experimental/Investigational: 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 05.00.85 Leadless Pacemakers as Medically Necessary: 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0826T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 05.00.85 Leadless Pacemakers as Experimental/Investigational: 0823T, 0824T, 0825T.

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is being communicated in Medical Policy 11.00.16 Ablation of Lung Tumors: 0600T, 0601T.

The following CPT code has been removed from Attachment A of this policy because its coverage position is being communicated in Medical Policy 06.02.01 Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy as Experimental/Investigational: 0580U.​

HCPCS CODES

The following HCPCS code has been removed from Attachment A of this policy because its coverage position is being communicated in Medical Policy 05.00.86 Remote Electrical Neuromodulation for Migraines as Medically Necessary: A4540.

The following HCPCS code has been removed from Attachment A of this policy because it is considered eligible: C1062.

The following HCPCS code has been removed from Attachment A of this policy because its coverage position is being communicated in Medical Policy 05.00.85 Leadless Pacemakers as Medically Necessary: C1605.

The following HCPCS codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 11.02.29 Renal Denervation for Uncontrolled Hypertension as Experimental/Investigational: C1735, C1736.

UNLISTED CODES

The following services are reported with unlisted code 38999:
  • Lymphaticovenous bypass (LVB)
  • Lymphovenous Bypass
These services are being removed from Attachment B of this policy because they can be reported with the following CPT code: 1019T.

The following services are reported with unlisted code A4335:
  • Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
  • Activation device for intraurethral drainage device with valve, replacement only, each
  • Charger and base station for intraurethral activation device, replacement only
These services are being removed from Attachment B of this policy because they can be reported with the following HCPCS codes: A4341, A4342.

TERMINATED

CPT CODES

The following CPT codes have been terminated (effective 01/01/2026) and removed from Attachment A of this policy: 0631T, 0361U, 0550U, 0551U.

TERMINATED AND REPLACED

CPT CODES

The following CPT codes have been terminated (effective 01/01/2026) and removed from Attachment A and replaced with a CPT code:
REMOVED: 0720T 
REPLACED WITH: 64567 

REMOVED: 0266T 
REPLACED WITH: 64654 

REMOVED: 0267T 
REPLACED WITH: 64655 

REMOVED: 0268T 
REPLACED WITH: 64656 

REMOVED: 0269T 
REPLACED WITH: 64657 

REMOVED: 0270T 
REPLACED WITH: 64658 

REMOVED: 0271T 
REPLACED WITH: 64659 

REMOVED: 0623T, 0624T, 0625T, 0626T

REPLACED WITH: 75577


REMOVED: 0272T 
REPLACED WITH: 93145 

REMOVED: 0273T 
REPLACED WITH: 93146 

​REVISIONS

CPT CODES

The following CPT code narratives (effective 01/01/2026) have been revised in Attachment A of this policy: 27278, 0598T, 0599T.

HCPCS CODES

The following HCPCS code narratives (effective 01/01/2026) have been revised in Attachment A of this policy: A2005, A2006, A2029, Q4150, Q4285, Q4286, Q4313, Q4315, Q4316, Q4323, Q4324, Q4334, Q4335, Q4343, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353, Q4360, Q4369, Q4391.


Revisions From 12.01.01br:
10/01/2025


This version of the policy will become retroactively effective 10/01/2025.

ADDITIONS

CPT CODES
The following CPT codes are new for 10/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: 0577U, 0579U, 0580U, 0581U, 0584U, 0589U, 0591U, 0594U, 0596U, 0598U, 0599U.

The following CPT code is Experimental/Investigational, and has been added to Attachment A of this policy: 0415U.

HCPCS CODES
The following HCPCS codes are new for 10/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: C1740, C1742, C8006, Q4391.


UNLISTED CODES

The following services are reported with unlisted code 38999, are Experimental/Investigational, and have been added to Attachment B of this policy:

  • ​Lymphaticovenous bypass (LVB)
  • Lymphovenous Bypass
  • Lymphaticovenous anastomosis (LVA)
  • Lymphovenous anastomosis
The following service is reported with unlisted code 43499, is Experimental/Investigational, and has been added to Attachment B of this policy:
  • Peroral Plication of the Esophagus (POPE)
The following service is reported with unlisted code 43499, is Experimental/Investigational, and has been added to Attachment B of this policy:
  • Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD)
The following service is reported with unlisted code 43999, is Experimental/Investigational, and has been added to Attachment B of this policy:
  • Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD)
The following service is reported with unlisted code 45399, is Experimental/Investigational, and has been added to Attachment B of this policy:
  • ​Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD)​
REMOVALS

CPT CODES
The following CPT code is considered Medically Necessary, and has been removed from Attachment A of this policy: 43497.

The following CPT code is used to report Freespira, and has been removed from Attachment C of this policy because Freespira is addressed in the Prescription Digital Therapeutics and Mobile-Based Health Management Applications policy (12.00.05): 90901.

The following CPT codes are now eligible when used to report the Treatment of Twin-Twin Transfusion Syndrome (TTTS), and have been removed from Attachment C of this policy: 57160, 59320, 59325.

HCPCS CODES
The following HCPCS code is being removed from Attachment A of this policy because its Experimental/Investigational coverage position is being communicated in Medical Policy 11.00.16 Ablation of Lung Tumors: C8005.

The following HCPCS codes are considered eligible, and have been removed from Attachment A of this policy: C9758, C9760​, C9782, C9783, C9792.
 
The following HCPCS codes are considered Medically Necessary, and have been removed from Attachment A of this policy: C1603, C9779.

The following HCPCS codes are now eligible when used to report the Treatment of Twin-Twin Transfusion Syndrome (TTTS), and have been removed from Attachment C of this policy: A4561, A4562, A4564.

TERMINATED

CPT CODES
The following CPT codes have been terminated and removed from Attachment A of this policy: 0450U, 0451U. 

REVISIONS

HCPCS CODES
​The following HCPCS code narratives (effective 10/01/2025) have been revised in Attachment A of this policy: C1739, C1982.


Revisions From 12.01.01bq:
07/01/2025


This version of the policy will become retroactively effective 07/01/2025.

ADDITIONS

CPT CODES

The following CPT codes are new for 07/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: 0948T, 0949T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0963T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, 0987T, 0558U, 0559U, 0568U, 0570U, 0573U, 0574U

HCPCS CODES

The following HCPCS code is new for 07/01/2025, is Experimental/Investigational, and has been added to Attachment A of this policy: Q4369​


REMOVALS

CPT CODES

The following CPT codes are considered Medically Necessary for peripheral nerve injury repair using synthetic conduits or processed nerve allografts, and have been removed from Attachment A of this policy: 64912, 64913

UNLISTED CODES

The following service is reported with unlisted code 46999, and has been removed from Attachment B of this policy because the service is now reported using CPT code 0963T:

  • Anoscopy with directed submucosal injection of bulking agent for fecal incontinence​
The following service is reported with unlisted code 43499, and has been removed from Attachment B of this policy because the service is addressed in the Peroral Endoscopic Myotomy (POEM) Procedures policy (11.03.17): 

  • ​Per-Oral Endoscopic Myotomy (POEM)
The following services are reported with unlisted code 43999, and have been removed from Attachment B of this policy because the services are addressed in the Peroral Endoscopic Myotomy (POEM) Procedures policy (11.03.17):

  • ​Gastric Per Oral Endoscopic Myotomy (G-POEM)
  • Per Oral Pyloromyotomy (POP)

TERMINATED


HCPCS CODES

The following HCPCS code has been terminated and removed from Attachment A of this policy: M0248 

REVISIONS

HCPCS CODES

The following HCPCS narrative (effective 07/01/2025) has been revised in Attachment A of this policy: C8005



Revisions From 12.01.01bp:
04/01/2025


This version of the policy will become retroactively effective 04/01/2025.

ADDITIONS

CPT CODES

The following CPT codes are new for 04/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: 0535U, 0541U, 0542U, 0545U, 0546U, 0547U, 0548U, 0550U, 0551U

HCPCS CODES

The following HCPCS codes are new for 04/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: C8004, C8005, G0183, G0566, Q4360, S4024​


UNLISTED CODES

The following services are reported with unlisted code 64999, are Experimental/Investigational, and have been added to Attachment B of this policy:
  • ​Pericapsular Nerve Group Block
  • PENG Block
REMOVALS

HCPCS CODES

The following HCPCS codes has been removed from Attachment A of this policy because their Experimental/Investigational coverage position is being communicated in Medical Policy 11.03.02 Bariatric Surgery: C9784, C9785

TERMINATED

CPT CODES

The following CPT codes have been terminated (effective 01/01/2025) and removed from Attachment A of this policy: 0553T, 0567T, 0568T

HCPCS CODES

The following HCPCS codes have been terminated (effective 04/01/2025) and removed from Attachment A of this policy: M0220, M0221, M0222, M0223, M0240, M0241, M0243, M0244, M0245, M0246, M0247, Q0220, Q0221, Q0222, Q0240, Q0243, Q0244, Q0245, Q0247

TERMINATED AND REPLACED

HCPCS CODES

The following HCPCS code has been terminated (effective 04/01/2025) and removed from Attachment A of this policy and replaced with a HCPCS code:
REMOVED: S4988
REPLACED WITH: E0201

REVISIONS

HCPCS CODES

The following HCPCS narrative (effective 04/01/2025) has been revised in Attachment A of this policy: C1739


Revisions From 12.01.01bo:
01/01/2025

This version of the policy will become retroactively effective 01/01/2025.

ADDITIONS

CPT CODES

The following CPT codes are new for 01/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: 51721, 55881, 55882, 60660, 60661, 64466, 64467, 64468, 64469, 64473, 64474, 82233, 82234, 83884, 84393, 84394, 0901T, 0902T, 0903T, 0904T, 0906T, 0907T, 0913T, 0914T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T, 0930T, 0931T, 0932T, 0933T, 0934T, 0935T, 0936T, 0944T, 0945T, 0946T, 0947T, 0521U, 0522U, 0524U, 0525U, 0526U

The following CPT code is Experimental/Investigational, and has been added to Attachment A of this policy: 0783T 

​​The following CPT codes are considered Experimental/Investigational when used for the treatment of Twin-Twin Transfusion Syndrome (TTTS), and have been added to Attachment C of this policy: 57160, 59320, 59325

The following CPT codes are considered Experimental/Investigational when used to report the Syn-One Test, and have been added to Attachment C of this policy: 88305, 88314, 88346, 88350, 88356

HCPCS CODES

The following HCPCS codes are new for 01/01/2025, are Experimental/Investigational, and have been added to Attachment A of this policy: C1735, C1736, C1738, C1739, C7563, C8003, C9610, C9806, C9807, C9808, C9809, G0555, G0561, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353​

The following HCPCS codes are Experimental/Investigational, and have been added to Attachment A of this policy: A4341, A4342

The following HCPCS codes are considered Experimental/Investigational when used for the treatment of Twin-Twin Transfusion Syndrome (TTTS), and have been added to Attachment C of this policy​: A4561, A4562, A4564

REMOVALS

CPT CODES

​The following CPT code has been removed from Attachment A of this policy because its Medically Necessary coverage position is being communicated in Medical Policy 09.00.56 Radiation Therapy Services: 0747T 

TERMED

CPT CODES

The following CPT code has been termed (effective 01/01/2025) and removed from Attachment A of this policy: 0346U

HCPCS CODES

The following HCPCS code has been termed (effective 01/01/2025) and removed from Attachment A of this policy: C9786

TERMED AND REPLACED

CPT CODES

The following CPT codes have been termed (effective 01/01/2025) and removed from Attachment A and replaced with a CPT code:

REMOVED: 0616T, 0617T, 0618T
REPLACED WITH: 66683

REVISIONS

CPT CODES

The following CPT narratives (effective 01/01/2025) have been revised in Attachment A of this policy: 98975, 98976, 98978, 0615T, 0095U, 0365U​


Revisions From 12.01.01bn:
10/01/2024This version of the policy will become retroactively effective 10/01/2024.

ADDITIONS

CPT CODES

The following CPT codes are considered Experimental/Investigational, and have been added to Attachment A of this policy: 97610, 0719T, 0858T.

The following CPT codes are new for 10/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: 0479U, 0482U, 0490U, 0491U, 0492U, 0503U, 0511U, 0512U, 0513U.

HCPCS CODES

The following HCPCS codes are new for 10/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: A2029, A4543, A4544, C8000, E0683, E0715, E0716, E0721, E0743, E3200, L8720, L8721, P9027, Q4334, Q4335, Q4343.

UNLISTED CODES

The following services are reported with unlisted codes 81599 and 84999, are Experimental/Investigational, and have been added to Attachment B of this policy.
  • ​Serum biomarker tests for multiple sclerosis
  • gMS Dx
  • gMS Pro EDSS
  • Octave Multiple Sclerosis Disease Activity (MSDA) test
The following service is reported with unlisted code 33999, is Experimental/Investigational, and has been added to Attachment B of this policy due to the archival of Medical Policy 11.02.22 Transcatheter Closure of Cardiac Septal Defects:
  • Transmyocardial Transcatheter Closure of Ventricular Septal Defect​
REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is being communicated in Medical Policy 11.17.04 Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence: 0587T, 0588T, 0589T, 0590T

The following CPT code has been removed from Attachment A of this policy because it is considered Medically Necessary: 90683

REVISIONS

CPT CODES

The following CPT narrative (effective 10/01/2024) has been revised in Attachment A of this policy: 0248U

HCPCS CODES

The following HCPCS narrative (effective 10/01/2024) has been revised in Attachment A of this policy: E0739


Revisions From 12.01.01bm:
07/01/2024This version of the policy will become retroactively effective 07/01/2024.

ADDITIONS

CPT CODES

The following CPT codes are new for 07/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: 0869T, 0870T, 0871T, 0872T, 0873T, 0874T, 0875T, 0876T, 0877T, 0878T, 0879T, 0880T, 0881T, 0882T, 0883T, 0884T, 0885T, 0886T, 0887T, 0893T, 0894T, 0895T, 0896T, 0897T, 0898T, 0899T, 0900T, 0450U, 0451U, 0457U, 0458U, 0459U, 0462U, 0472U

The following CPT code is considered Experimental/Investigational when used to report Quantitative Electroencephalography (EEG) as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder (ADHD)​, and has been added to Attachment C of this policy: 95957

HCPCS CODES

The following HCPCS codes are new for 07/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: C1605, J7355, Q4313, Q4315, Q4316, Q4323, Q4324

REMOVALS

CPT CODES

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is being communicated in Medical Policy 07.03.22 Transcranial Magnetic Stimulation (TMS): 0858T

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage positions are being communicated in Medical Policy 11.17.06 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH): 53855, 0619T

The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage positions are being communicated in Medical Policy 07.00.01 Biofeedback Therapy: 90875, 90876

HCPCS CODES

The following HCPCS code has been removed from Attachment A of this policy because its Experimental/Investigational​ coverage position is being communicated in Medical Policy 11.17.06 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH): C9769

REMOVED AND REPLACED

HCPCS CODES

The following HCPCS codes have been removed (effective 07/01/2024) from Attachment A and replaced with CPT codes:

REMOVED: C9787
REPLACED WITH: 0868T
REMOVED: C9790
REPLACED WITH: 0888T


Revisions From 12.01.01bl:
04/01/2024This version of the policy will become retroactively effective 04/01/2024.

ADDITIONS

CPT CODES

The following CPT codes are new for 04/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: 0441U, 0442U, 0443U, 0445U, 0446U, 0447U

HCPCS CODES

The following HCPCS codes are new for 04/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: A4438, A4593, A4594, C9796, C9797, E0738, E0739, S4988

UNLISTED CODES

The following services are reported with unlisted code 64999, are Experimental/Investigational, and have been added to Attachment B of this policy:
  • ​Popliteal Artery and the Capsule of the Knee (iPACK) block
  • iPACK block​
REMOVALS

CPT CODES

The following CPT code is considered Medically Necessary and has been removed from Attachment A of this policy: 55867​

Revisions From 12.01.01bk:
01/01/2024This version of the policy will become retroeffective 01/01/2024.

ADDITIONS

CPT CODES

The following CPT codes are new for 01/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: 27278, 31242, 31243, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 52284, 64596, 64597, 64598, 90683, 92972, 93150, 93151, 93152, 93153, 0811T, 0812T, 0813T, 0814T, 0815T, 0820T, 0821T, 0822T, 0823T, 0824T, 0825T, 0826T, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 0857T, 0858T, 0859T, 0860T, 0861T, 0862T, 0863T, 0865T, 0866T, 0427U, 0430U, 0431U, 0432U, 0435U, 0436U  

The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0063U, 0263U, 0322U

HCPCS CODES

The following HCPCS codes are new for 01/01/2024, are Experimental/Investigational, and have been added to Attachment A of this policy: A4540, A4541, A4542. C1600, C1601, C1602, C1603, C1604, E0530, E0678, E0679, E0680, E0681, E0682, E0733, E0734, E3000

The following HCPCS code is considered Experimental/Investigational and has been added to Attachment A of this policy: Q4233

UNLISTED CODES

The following unlisted code is used to represent Auditory Integration Training (AIT), which is considered Experimental/Investigational, and has been added to Attachment B of this policy: 97139

The following unlisted code is used to represent Facilitative Communication (FC), which is considered Experimental/Investigational, and has been added to Attachment B of this policy: 97139

The following services are reported with unlisted code 81479, are Experimental/Investigational, and have been added to Attachment B of this policy:

  • ​Panel testing using next generation sequencing (NGS) for genetic (i.e., DNA and/or RNA) testing for Autism Spectrum Disorder (ASD)
  • Genetic testing (DNA and/or RNA) panel testing for Autism Spectrum Disorder (ASD)
The following unlisted codes are used to represent Regeneten Bioinductive Implant, which is considered Experimental/Investigational, and has been added to Attachment B of this policy: 17999, C1889

REMOVALS

CPT CODES

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is being communicated in Medical Policy 06.02.01 Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy: 0316U

HCPCS CODES

The following HCPCS code has been removed from Attachment A of this policy because its Medically Necessary coverage position (retro-effective to 10/01/2023) is being communicated in Medical Policy 05.00.59 Lower Limb Prostheses: L5991

UNLISTED CODES

The following services have been removed from Attachment B of this policy because there is a specific code (J1413) used to report these services. The coverage position for J1413 is being communicated in Medical Policy 08.02.13 Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; ELEVIDYS®):
​
  • ​Delandistrogene moxeparvovec-rokl (ELEVIDYS)
  • Delandistrogene moxeparvovec-rokl
  • ELEVIDYS
The services above were reported with the following unlisted codes, which have been removed from Attachment B of this policy: C9399, J3590

TERMED CODES (i.e., NO LONGER A VALID CODE)

CPT CODES

The following CPT codes have been termed (effective 01/01/2024) and have been removed from Attachment A of this policy: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 0465T, 0499T, 0533T, 0534T, 0535T, 0536T, 0641T, 0642T, 0715T, 0768T, 0769T, 0775T, 0809T

HCPCS CODES

The following HCPCS codes have been termed (effective 01/01/2024) and have been removed from Attachment A of this policy: C9771, C9788, K1001, K1009, K1016, K1017, K1018, K1019, K1023, K1024, K1025, K1031, K1032, K1033

REVISIONS

CPT CODES

The following CPT narratives (effective 01/01/2024) have been revised in Attachment A of this policy: 0517T, 0519T, 0520T, 0521T, 0522T, 0587T, 0588T, 0589T, 0590T, 0640T, 0766T, 0767T, 0351U

The following CPT narrative (effective 01/01/2024) have been revised in Attachment C of this policy: 64590​


Revisions From 12.01.01bj:
10/01/2023This version of the policy will become retroeffective 10/01/2023.

ADDITIONS

CPT CODES
The following CPT codes are new for 10/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: 0019M, 0404U, 0407U, 0412U

The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0745T, 0746T, 0747T

HCPCS CODES
The following HCPCS codes are new for 10/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: A9268, A9269, C9788, C9790, C9791, C9792, K1036, L5991, Q4285, Q4286

UNLISTED CODES
The following services are considered Experimental/Investigational:
  • delandistrogene moxeparvovec-rokl (ELEVIDYS)
  • delandistrogene moxeparvovec-rokl
  • ELEVIDYS
The following unlisted codes are used to report the services above and have been added to Attachment B of this policy: C9399, J3590

REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medical Policy 11.02.25 Transcatheter Cardiac Valve Procedures: 33370, 93590, 93591, 93592, 0483T, 0484T, 0544T, 0545T, 0646T, 0805T, 0806T

TERMED CODES (i.e., NO LONGER A VALID CODE)

CPT CODES

The following CPT codes have been termed (effective 10/1/2023) and have been removed from Attachment A of this policy: 0066U, 0357U

REVISIONS

HCPCS CODES

The following HCPCS narrative (effective 10/1/2023) have been revised in Attachment A of this policy: K1004​​

Revisions From 12.01.01bi:
07/01/2023This version of the policy will become retro-effective 07/01/2023.

ADDITIONS

CPT CODES
The following CPT codes are new for 07/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: 0791T, 0793T, 0794T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0805T, 0806T, 0807T, 0808T, 0809T, 0387U, 0390U, 0393U, 0394U, 0399U

The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 62263, 62264, 77089, 77090, 77091, 77092

The following CPT code is considered Experimental/Investigational when used to report BioZorb, and has been added to Attachment C of this policy: 15777

HCPCS CODES
The following HCPCS codes are new for 07/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: C9784, C9795, C9786, C9787

The following HCPCS codes are considered Experimental/Investigational and have been added to Attachment A of this policy: M0220, M0221, M0222, M0223, M0240, M0241, M0243, M0244, M0245, M0246, M0247, M0248, Q0220, Q0221, Q0222, Q0240, Q0243, Q0244, Q0245, Q0247

The following HCPCS code is considered Experimental/Investigational when used to report BioZorb, and has been added to Attachment C of this policy: C9728

UNLISTED CODES
The following Unlisted code is used to report Endoscopic Lysis of Epidural Adhesions, and is considered Experimental/Investigational and has been added to Attachment B of this policy: 64999

REMOVALS

CPT CODES
The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 30468, 76883

The following CPT codes have been removed from Attachment A of this policy because their coverage positions are being communicated in separate Medical Policies: 90678, 0687T, 0688T, 0704T, 0705T, 0706T, 0740T, 0741T

HCPCS CODES
The following HCPCS codes are considered Not Medically Necessary and have been removed from Attachment A of this policy: J9247, J9285

The following HCPCS code has been removed from Attachment A of this policy because its coverage position is being communicated in separate Medical Policy: A9291

UNLISTED CODES
The following Unlisted code is used to report Freespira®, and has been removed from Attachment B of this policy because its coverage position is being communicated in separate Medical Policy: E1399

REVISIONS
CPT CODES
The following CPT narratives (effective 7/1/2023) have been revised in Attachment A of this policy: 0308U, 0309U, 0310U​



Revisions From 12.01.01bh:
04/01/2023This version of the policy will become retro-effective 04/01/2023.

ADDITIONS

CPT CODES

The following CPT codes are new for 04/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: 0365U, 0366U, 0367U, 0375U, 0376U, 0377U, 0381U, 0382U, 0383U, 0384U, 0385U

The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 98975, 98976, 98980, 98981, 0775T

HCPCS CODES

The following HCPCS code is new for 04/01/2023, is Experimental/Investigational, and has been added to Attachment A of this policy: A2020

The following HCPCS codes are considered Experimental/Investigational and have been added to Attachment A of this policy: C9782, C9783

REMOVALS

HCPCS CODES

The following HCPCS code is considered Medically Necessary and has been removed from Attachment A of this policy: C1886​


TERMED CODES (i.e., NO LONGER A VALID CODE)

CPT CODES

The following CPT codes have been termed (effective 4/1/2023) and have been removed from Attachment A of this policy: 0324U, 0325U

REVISIONS

CPT CODES

The following CPT narrative has been revised in Attachment A of this policy: 0095U

HCPCS CODES

The following HCPCS narrative has been revised in Attachment A of this policy: K1019


Revisions From 12.01.01bg:
01/01/2023This version of the policy will become retro-effective 01/01/2023.

ADDITIONS

CPT CODES

The following CPT codes are new for 01/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: 36836, 36837, 43290, 43291, 55867, 76883, 90678, 95919, 0738T, 0739T, 0740T, 0741T, 0743T, 0744T, 0748T, 0749T, 0750T, 0751T, 0752T, 0753T, 0754T, 0755T, 0756T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T, 0764T, 0765T, 0766T, 0767T, 0768T, 0769T, 0770T, 0771T, 0772T, 0773T, 0774T, 0776T, 0777T, 0778T, 0779T, 0781T, 0782T, 0357U, 0358U, 0359U, 0360U, 0361U

HCPCS CODES

The following HCPCS codes are new for 01/01/2023, are Experimental/Investigational, and have been added to Attachment A of this policy: C1747, C1826, C1827

HCPCS code C7532 is new for 01/01/2023, and has been added to Attachment C of this policy. HCPCS code C7532 is Experimental/Investigational when reported for the following services: 
  • ​Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
REMOVALS

CPT CODES

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is communicated in Medical Policy 07.05.02 Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders: 0651T

The following CPT code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is communicated in Medical Policy 07.03.07 Evaluation and Management of Autism Spectrum Disorder (ASD): 0063U

TERMED CODES (i.e., NO LONGER A VALID CODE)

CPT CODES

The following CPT code has been termed (effective 1/1/2023) and has been removed from Attachment A of this policy: 0514T

The following CPT codes have been termed (effective 1/1/2023) and have been removed from Attachment A of this policy and are replaced by the following Unlisted code in Attachment B:

REMOVED: 0470T, 0471T

REPLACED WITH: 96999


​REMOVED: 0475T, 0476T, 0477T, 0478T

​REPLACED WITH: 93799

REMOVED: 0487T

REPLACED WITH: 58999

REMOVED: 0491T, 0492T

​REPLACED WITH: 17999

​REMOVED: 0493T

​REPLACED WITH: 93998


The following CPT codes have been termed (effective 1/1/2023) and have been removed from Attachment A of this policy and are replaced by the following CPT code in Attachment A:

​REMOVED: 0702T, 0703T
REPLACED WITH: 98978

REVISIONS

CPT CODES

The following CPT narratives have been revised in Attachment A of this policy: 0733T, 0734T

HCPCS CODES

The following HCPCS narrative has been revised in Attachment A of this policy: C1831​

Revisions From 12.01.01bf:
10/01/2022This version of the policy will become retro-effective 10/01/2022.

ADDITIONS

The following CPT codes are new for 10/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy:​ 0337U, 0338U, 0342U, 0346U, 0351U

The following CPT codes are Experimental/Investigational, and have been added to Attachment A of this policy: 0702T, 0703T

The following CPT/HCPCS codes are considered Experimental/Investigational when used to report ReActiv8, and have been added to Attachment C of this policy: 64555, 64575, 64590, C1767, C1778, C1787, L8679, L8680, L8683

The following HCPCS code is new for 10/01/2022, is Experimental/Investigational, and has been added to Attachment A of this policy: A2017

REMOVALS

The following CPT codes are Experimental/Investigational, and have been removed from Attachment A of this policy because their coverage position is communicated in Medical Policy 07.07.09 Stem-Cell Therapy/Platelet-Rich Plasma for Orthopedic Applications and Platelet-Rich Plasma/Platelet-Derived Growth Factor for Wound Healing and Other Miscellaneous Non-Orthopedic Conditions: 0263T, 0264T, 0265T

​REVISIONS

The following HCPCS codes have been revised in Attachment A as follows:

A9291:
FROM: Prescription digital behavioral therapy, FDA-cleared, per course of treatment
TO: Prescription digital cognitive and/or behavioral therapy, fda cleared, per course of treatment

K1019:
FROM: Monthly supplies for use of device coded at K1018
​TO: Replacement supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist​


Revisions From 12.01.01be:
07/01/2022This version of the policy will become retro-effective 07/01/2022.

ADDITIONS

The following CPT codes are new for 07/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy: 0715T, 0716T, 0717T, 0718T, 0720T, 0721T, 0722T, 0723T, 0724T, 0725T, 0726T, 0727T, 0728T, 0729T, 0730T, 0731T, 0732T, 0733T, 0734T, 0736T, 0737T, 0324U, 0325U, 0328U

The following HCPCS code is Experimental/Investigational, and has been added to Attachment A of this policy: K1023

REMOVALS

The following services are represented by Unlisted code E1399, and have been removed from Attachment B of this policy, and replaced with CPT Code 0720T in Attachment A:
  • ​IB-Stim for functional abdominal pain
  • Percutaneous electrical nerve field stimulator (PENFS) system for functional abdominal pain
The following service is represented by Unlisted codes 88199, 88299, 89240, and has been removed from Attachment B of this policy because this service is addressed in Medical Policy 06.02.35 Genetic Testing: 
  • Whole Exome Sequencing​​

Revisions From 12.01.01bd:
04/01/2022This version of the policy will become retro-effective 04/01/2022.

ADDITIONS

The following CPT codes are new for 04/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy: 0308U, 0309U, 0310U, 0312U, 0316U​

The following HCPCS codes are new for 04/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy: A9291, C9781, K1030, K1031, K1032, K1033

The following service, which is represented by Unlisted code 41599, is Experimental/Investigational and has been added to Attachment B of this policy:

  • Carbon Dioxide Laser Ablation of Oral Lesions
The following service, which is represented by Unlisted code 76999, is Experimental/Investigational and has been added to Attachment B of this policy:

  • Use of DynaCAD Prostate
Electrical cell signaling treatment (EST), in the treatment of pain and other indications utilizing devices such as, RST- Sanexas neoGEN Series System, Sanexas, and neoGEN System, is considered Experimental/Investigational has been added to Attachment B of this policy.

REMOVALS

The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 31647, 31651, 33274, 58674, 68841, 0404T

Revisions From 12.01.01bc:
01/10/2022This version of the policy will become effective 01/10/2022.

ADDITIONS

The following CPT codes are considered Experimental/Investigational, and have been added to Attachment A of this policy: 0510T, 0530T, 0531T, 0532T, 0550T, 0573T, 0580T, 0588T
________________________________________________________________________

NOTE:​ On 12/28/2021, this policy was updated with the following coding changes effective 01/01/2022.

ADDITIONS

The following CPT codes are new for 01/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy: 33267, 33268, 33269, 33370, 43497, 53453, 53454, 61736, 61737, 81560, 0672T, 0673T, 0674T, 0675T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0686T, 0687T, 0688T, 0689T, 0690T, 0691T, 0692T, 0693T, 0694T, 0695T, 0696T, 0697T, 0698T, 0700T, 0701T, 0704T, 0705T, 0706T, 0708T, 0709T, 0710T, 0711T, 0712T, 0713T, 0295U, 0303U, 0304U, 0305U​

The following HCPCS codes are new for 01/01/2022, are Experimental/Investigational, and have been added to Attachment A of this policy: A2005, A2006, C1832, E1629

The following HCPCS code is Experimental/Investigational, and has been added to Attachment A of this policy: J9247

The following Unlisted code has been removed from Attachment B and is replaced with the new CPT code for 01/01/2022, which has been added to Attachment A of this policy:

REMOVED: 27599 (used to report Subchondroplasty and Subchondroplasty (SCP) Procedure)
​REPLACED WITH: 0707T 

TERMED CODES (i.e., NO LONGER A VALID CODE)

The following CPT code has been termed and has been removed from Attachment A of this policy: 0550T

The following CPT codes have been termed and have been removed from Attachment A of this policy and are replaced by the following Unlisted codes in Attachment B:

REMOVED: 0290T

REPLACED WITH: 66999

REMOVED: 0423T

REPLACED WITH: 84999

REMOVED: 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T

REPLACED WITH: 33999​

The following CPT codes have been termed and have been removed from Attachment A of this policy and are replaced by the following CPT codes in Attachment A:


REMOVED: 0356T

REPLACED WITH: 68841

REMOVED: 0548T

REPLACED WITH: 53451

REMOVED: 0549T

REPLACED WITH: 53452

​The following HCPCS codes have been termed and have been removed from Attachment A of this policy and are replaced by the following CPT codes in Attachment A:

REMOVED: C9752 

REPLACED WITH: 64628

REMOVED: C9753 

REPLACED WITH: 64629

REVISIONS

The following CPT narratives have been revised in Attachment A of this policy: 0512T, 0513T, 0648T, 0649T

The following HCPCS narrative has been revised in Attachment A of this policy: C9777​

Revisions From 12.01.01bb:
10/01/2021This version of the policy will become effective 10/01/2021.

ADDITIONS
​
The following CPT codes are new for 10/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: 0018M, 0255U, 0259U, 0261U

The following HCPCS codes are new for 10/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: C1831, C9779, C9780, K1024, K1025​

​​TERMED CODES (i.e., NO LONGER A VALID CODE)

The following CPT code has been termed and has been removed from Attachment A of this policy: 0139U

The following HCPCS code has been termed and has been removed from Attachment A of this policy: ​​C9075

Revisions From 12.01.01ba:
07​​/12/2021This version of the policy will become effective 07/12/2021.

ADDITIONS

The following HCPCS code is now considered Experimental/Investigational, and has been added to Attachment A of this policy: C9757

Procedure code C9757, represents annulus repair devices, including Xclose Tissue Repair System, Barricaid, Disc Annular Repair Technology (DART) System, and Inclose Surgical Mesh System. A comprehensive review of these technologies has determined them to be Experimental/Investigational, as the current state of evidence for these technologies does not support the safety and effectiveness for them.
_________________________________________________________________________

NOTE:​ On 07/08/2021, this policy was updated with the following coding changes effective 07/01/2021.

ADDITIONS
The following CPT codes are new for 07/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy:  0640T, 0641T, 0642T, 0643T, 0645T, 0646T, 0647T, 0648T, 0649T, 0651T, 0652T, 0653T, 0654T, 0655T, 0658T, 0659T, 0660T, 0661T, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T, 0248U, 0249U, 0251U

​The following HCPCS codes are new for 07/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: C1761, C9075

The following HCPCS code is Experimental/Investigational, and has been added to Attachment A of this policy: ​E0740

The following procedure is represented by unlisted code 37799, it is considered Experimental/Investigational, and has been added to Attachment B of this policy:
  • Insertion of TriGUARD 3 Cerebral Embolic Protection Device
The following procedure is represented by unlisted code 53899, it is considered Experimental/Investigational, and has been added to Attachment B of this policy:
  • Magnetic Pelvic Floor Stimulation (MPFS)
The following procedure is represented by unlisted code 60699, it is considered Experimental/Investigational, and has been added to Attachment B of this policy:
  • Radiofrequency Ablation of a Benign Thyroid Nodule
Unlisted code C1889 is used to represent the following Experimental/Investigational devices, and has been added to Attachment B of this policy:
  • SENTINEL™ Cerebral Protection
  • TriGUARD 3 Cerebral Embolic Protection Device
  • Distal Occlusion Device
REMOVALS
The following services are represented by unlisted code 37799, and have been removed from Attachment B of this policy because they are addressed in Medical Policy 11.02.12 Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery:
  • Filterwire EZ Embolic Protection System
  • Embolic Protection Device (EPD)
  • Proximal Occlusion Device
REVISIONS
The following CPT narrative has been revised in Attachment A of this policy: 0493T
​
The following services are represented by unlisted code 37799, and have been revised in Attachment B of this policy as follows:
FROM: 
    • SENTINEL™ Cerebral Protection
    • Distal Occlusion Device
TO:
    • Insertion of SENTINEL™ Cerebral Protection
    • Insertion of Distal Occlusion Device​

Revisions From 12.01.01az:
04​​/01/2021This version of the policy will become effective 04/01/2021.

ADDITIONS

The following CPT codes are new for 04/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: 0243U, 0247U

The following HCPCS codes are new for 04/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: C9776, C9777, K1016, K1017, K1018, K1019

The following services are represented by unlisted code E1399, are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • IB-Stim for functional abdominal pain
  • Percutaneous electrical nerve field stimulator (PENFS) system for functional abdominal pain​​
REMOVALS

The following HCPCS code is considered Medically Necessary, and has been removed from Attachment A of this policy: C9751

The following procedure is represented by unlisted code 92499 and is considered Medically Necessary, and has been removed from Attachment B of this policy:
  • Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report​​
TERMED CODES (i.e., NO LONGER A VALID CODE)

The following HCPCS codes have been termed and have been removed from Attachment A of this policy and are replaced by the following Unlisted Code in Attachment B:

REMOVED: K1010, K1011, K1012

REPLACED WITH: A4335​


Revisions From 12.01.01ay:
01​​/01/2021This version of the policy will become effective 01/01/2021.

ADDITIONS

The following CPT codes are new for 01/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: 55880, 57465, 0620T, 0621T, 0622T, 0623T, 0624T, 0625T, 0626T, 0627T, 0628T, 0629T, 0630T, 0631T, 0632T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0639T

The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 64625, 0200T, 0201T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

The following HCPCS codes are new for 01/01/2021, are Experimental/Investigational, and have been added to Attachment A of this policy: C1062, C1825, C9771, C9772, C9773, C9774, C9775

The following HCPCS code is Experimental/Investigational and has been added to Attachment A of this policy: G0428

The following procedure is represented by unlisted code 64999 and is Experimental/Investigational, and has been added to Attachment B of this policy:
  • Epidural steroid injection(s) procedure(s) with ultrasound guidance​
The following procedure is represented by unlisted code 22899 and is Experimental/Investigational, and has been added to Attachment B of this policy:
  • Three or more levels of cervical total disc arthroplasty (artificial disc)​​
The following cell-based treatments for focal articular cartilage lesions are represented by unlisted code 27599 and are Experimental/Investigational, and have been added to Attachment B of this policy:
  • ​Matrix-induced autologous chondrocyte implantation for non-FDA approved products (e.g., ChondroCelect, BioCart II, Cartilix, Cartipatch)
  • Autologous minced cartilage
  • Allogeneic minced cartilage or cartilage cells (e.g., DeNovo NT Graft and DeNovo ET Live Chondral Engineered Tissue Graft [Neocartilage]​)
The following services represented by HCPCS code J7330 are considered Experimental/Investigational, and have been added to Attachment C of this policy:
  • ChondroCelect
  • BioCart II
  • Cartilix
  • Cartipatch
REMOVALS

The following CPT codes ​are Medically Necessary and have been removed from Attachment A of this policy: 87506, 87507

The following procedure is represented by unlisted code 69799 and is considered Medically Necessary, and has been removed from Attachment B of this policy:
  • Balloon dilation of eustachian tube​
TERMED CODES (i.e., NO LONGER A VALID CODE)

The following HCPCS code has been termed and has been removed​ from Attachment A of this policy: C9745​

The following HCPCS code has been termed and has been removed from Attachment A of this policy and is replaced by the following CPT code in Attachment A:

REMOVED: C9749
REPLACED WITH: 30468​

The following CPT codes have been termed and have been removed from Attachment A of this policy and are replaced by the following Unlisted Codes in Attachment B:

REMOVED: 0111T
REPLACED WITH: 84999
REMOVED: 0126T
REPLACED WITH: 93998​
REMOVED: 0381T, 0382T, 0383T, 0384T, 0385T, 0386T
REPLACED WITH: 95999​
REMOVED: 0400T, 0401T
REPLACED WITH: 96999
REMOVED: 0405T
REPLACED WITH: 99499

REVISIONS

The following HCPCS narrative has been revised in Attachment A of this policy: C9760

Revisions From 12.01.01ax:
10/01/2020The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 0015M, 0206U, 0207U​

The following HCPCS codes are Experimental/Investigational and have been added to Attachment A of this policy: C9768, C9769, K1007, K1009, K1010, K1011, K1012, Q4150

The following HCPCS code narratives have been revised in Attachment A of this policy: L8701, L8702

Revisions From 12.01.01aw:
07/01/2020The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 0594T, 0596T, 0597T, 0598T, 0599T, 0600T, 0601T, 0602T, 0603T, 0604T, 0605T, 0606T, 0607T, 0608T, 0609T, 0610T, 0611T, 0612T, 0613T, 0614T, 0615T, 0616T, 0617T, 0618T, 0619T, 0174U, 0176U, 0178U

The following HCPCS codes are Experimental/Investigational and have been added to Attachment A of this policy: C1748, C9759, C9760, C9764, C9765, C9766, C9767, Q4240, Q4241, Q4242

The following CPT codes have been termed (no longer valid codes) and removed from Attachment A of this policy: 0124U, 0125U, 0126U, 0127U, 0128U

The following CPT narratives have been revised in Attachment A of this policy: 0577T, 0165U

The following HCPCS code has been removed from Attachment A of this policy because its Experimental/Investigational coverage position is now communicated in Medical Policy 11.14.03 Meniscal Allograft Transplantation and Meniscal Implants: G0428

The following procedures are represented by unlisted code 27599 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Subchondroplasty
  • Subchondroplasty (SCP) Procedure
The following procedures are represented by unlisted code 92499 and are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Creation of Autologous serum tears
  • Creation of Autologous Serum eye drop(s)
The following services are considered Experimental/Investigational, and have been added to Attachment B of this policy:
  • Autologous serum tears
  • Autologous Serum eye drop(s)

Revisions From 12.01.01av:
04/01/2020The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 0165U, 0167U

The following HCPCS codes are Experimental/Investigational and have been added to Attachment A of this policy due to the archival of Medical Policy 07.07.07 Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds: G0281, G0282, G0295, G0329

The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 0446T, 0447T, 0448T

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 12.01.01au:
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 Medical Policy 11.17.06 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: 64454, 64624, 92549, 0547T, 0563T, 0567T, 0568T, 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 and is replaced by the following CPT code in Attachment A:
    REMOVED: 0249T
    REPLACED WITH: 46948
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 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, C9758, 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.

Revisions From 12.01.01at:
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 codes are considered Experimental/Investigational and have been added to Attachment A of this policy: J9285, Q4212, Q4213, Q4226

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 12.01.01as:
07/01/2019The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 0543T, 0544T, 0545T, 0549T, 0553T, 0559T, 0560T, 0561T, 0562T, 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 codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is communicated in Medical Policy 07.02.22 Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP): 43252, 0397T

Revisions From 12.01.01ar:
01/01/2019The following CPT codes are considered Experimental/Investigational and have been added to Attachment A of this policy: 33274, 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, 0080U, 0083U

The following CPT codes have been termed and have been removed from Attachment A of this policy: 0159T, 0195T, 0196T, 0337T, 0387T, 0388T, 0389T, 0390T, 0391T

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

The following CPT narrative has been revised in Attachment A of this policy: 0335T

The following HCPCS codes are considered Experimental/Investigational and have been added to Attachment A of this policy: A4563, C8937, C9751, C9752, C9753, 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 MP 08.00.18 Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk: 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:
  • Sphenopalatine 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 12.01.01aq:
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 code is considered Medically Necessary and has been removed from Attachment A of this policy: 55874

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

Revisions From 12.01.01ap:
07/23/2018The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is communicated in Medical Policy 07.02.21 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 12.01.01ao:
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 12.01.01an:
04/01/2018The following CPT codes have been added to Attachment A of this policy: 62280, 62281, 62282, 62292

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 because its coverage position is communicated in Medical Policy 05.00.39 Ankle-Foot/Knee-Ankle-Foot Orthoses:
  • A9285
The following CPT code has been removed from Attachment A of this policy:
  • 27279

Revisions From 12.01.01am:
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

Effective 10/05/2017 this policy has been updated to the new policy template format.
7/1/2026
7/24/2026
12.01.01
Medical Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.