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Experimental/Investigational Services
MA00.005at

Policy

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.

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 Misspelled Wordpr​Misspelled Wordocedure 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

​Evidence of Coverage

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 MA00.005at:
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. 

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, 0805T, 0806T, 0882T, 0883T. ​

​


Revisions From MA00.005as:
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: A8005, A8006, C1743, C8010, G0680.

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 code has been removed from Attachment A of this policy because its coverage position is being communicated in Medical Policy MA11.120 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 MA11.004 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 is considered eligible and has been removed from Attachment A of this policy: C9756.​

The following HCPCS code is considered Medically Necessary and has been removed from Attachment A of this policy: L2006.​


Revisions From MA00.005ar:
01/01/2026

​This version of the policy will be 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, 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, G0571.

The following HCPCS codes are Experimental/Investigational, and have been added to Attachment A of this policy because Medicare Advantage Policy MA07.011 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 Medicare Advantage policy MA07.011 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 Medicare Advantage Policy MA11.051 Treatment of Obesity and Bariatric Surgery for Treatment of Morbid Obesity as Not Covered: 43290, 43291, 0813T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA07.034 Laser Interstitial Thermal Therapy (LITT) as Medically Necessary: 61736, 61737.​

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA05.038 Cardiac Contractility Modulation as Experimental/Investigational with the exception of Coverage with Evidence Development (CED): 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0948T, 0949T.
 
The following CPT codes have been removed from Attachment A of this policy because their Experimental/Investigational coverage position is being communicated in Medicare Advantage Policy MA11.052 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 Medicare Advantage Policy MA06.006 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 Medicare Advantage Policy MA05.071 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 codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA05.038 Cardiac Contractility Modulation as Experimental/Investigational with the exception of Coverage with Evidence Development (CED): C1824, K1030.

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.

TERMINATED

CPT CODES
The following CPT codes have been terminated (effective 01/01/2026) and removed from Attachment A of this policy: 0631T, 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, 98978, 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 MA00.005aq:
10/01/2025

​This version of the policy will be 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 codes are considered Medically Necessary for renal denervation for uncontrolled hypertension, and have been removed from Attachment A of this policy: 0338T, 0339T.

The following CPT codes have been removed from Attachment A of this policy because their coverage position is addressed in the Transcatheter Cardiac Valve Procedures policy (MA11.027): 0569T, 0570T.

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 (MA12.011): 90901.

HCPCS CODES
The following HCPCS codes are considered Medically Necessary for renal denervation for uncontrolled hypertension, and have been removed from Attachment A of this policy: C1735, C1736. 

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 MA11.052 Ablation of Lung Tumors: C8005.

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

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 MA00.005ap:
07/01/2025

​This version of the policy will be 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.

The following CPT codes have been removed from Attachment A of this policy because their Medically Necessary coverage position is being communicated in a NewsFlash titled "The Aurora Extravascular Implantable Cardioverter Defibrillator (EV-ICD) System (Medtronic Inc.) for the treatment of life-threatening ventricular arrhythmias.": 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T.

The following CPT code has been removed from Attachment A of this policy because its coverage position is communicated in Medicare Advantage Policy MA11.027 Transcatheter Cardiac Valve Procedures: 0646T.

The following CPT code has been removed from Attachment A of this policy because its coverage position is being communicated in a NewsFlash titled “Updated Preventive Coverage for Colorectal Cancer Screening (Retroactively Effective)”: 0464U.

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 (MA11.117):
 
  • 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 (MA11.117):

  • ​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 MA00.005ao:
04/01/2025

​This version of the policy will be 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

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA11.119 Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management: 33289, 93264.

HCPCS CODES

The following HCPCS codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA11.119 Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management: C2624, G0555.

The following HCPCS codes has been removed from Attachment A of this policy because their Experimental/Investigational coverage position is being communicated in Medicare Advantage Policy MA11.051 Treatment of Obesity and Bariatric Surgery for Treatment of Morbid Obesity: 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 MA00.005an:
01/01/2025

​This version of the policy will be 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 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, G0555, G0561, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353.

​REMOVALS

CPT CODES

The following CPT codes have been removed from Attachment A of this policy because their Medically Necessary coverage position is being communicated in Medicare Advantage Policy MA09.020 Radiation Therapy Services: 0745T, 0746T, 0747T.

HCPCS CODES

The following HCPCS codes are considered Medically Necessary, and have been removed from Attachment A of this policy: A4542, E0734.

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: 98978, 0615T, 0095U.


Revisions From MA00.005am:
10/01/2024

​This version of the policy will be 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: 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, E0767, 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 Medicare Advantage Policy MA11.040 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 Medicare Advantage Policy MA11.028 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 its coverage position is being communicated in Medicare Advantage Policy MA08.007 Medicare Part B vs. Part D Crossover Drugs: 90683

HCPCS CODES

The following HCPCS code is considered Medically Necessary, and has been removed from Attachment A of this policy: L5615

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 MA00.005al:
07/01/2024

​This version of the policy will be 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, 0464U, 0472U

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: 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 Medicare Advantage Policy MA07.035 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 Medicare Advantage Policy MA11.004 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH): 53855, 0619T

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 Medicare Advantage Policy MA11.004​ 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 MA00.005ak:
04/01/2024

​This version of the policy will be 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 

The following CPT codes have been removed from Attachment A of this policy because their coverage position is being communicated in Medicare Advantage Policy MA05.067 Leadless Pacemakers: 0798T, 0799T, 0800T​

Revisions From MA00.005aj:
01/01/2024

​This version of the policy will be 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: 22836, 22837, 22838, 27278, 31242, 31243, ​52284, 64596, 64597, 64598, 90683, 92972, 0790T, 0811T, 0812T, 0813T, 0814T, 0820T, 0821T, 0822T, 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

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, J1413, L5615

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

UNLISTED CODES

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

Unlisted code 76999 is considered Experimental/Investigational when used to report the following service, and has been added to Attachment B of this policy:

  • Pulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia
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 Medicare Advantage Policy MA06.006 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 Medicare Advantage Policy MA05.024 Lower Limb Prostheses: L5991

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, 0508T, 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, K1014, 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, 0656T, 0657T, 0766T, 0767T, 0351U​

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

​​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​​

Revisions From MA00.005ai:
10/01/2023

​This version of the policy will be 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: 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

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

CPT CODES

The following CPT code has been termed (effective 10/1/2023) and has been removed from Attachment A of this policy: 0066U

REVISIONS

HCPCS CODES

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

Revisions From MA00.005ah:
07/01/2023

​This version of the policy will be 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, 0798T, 0799T, 0800T, 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, 0743T, 0749T, 0750T 

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, C9785, 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 MA00.005ag:
04/01/2023

​This version of the policy will be 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: 0381U, 0382U, 0383U

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


CPT CODES
The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 0743T, 0749T, 0750T

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 MA00.005af:
01/01/2023

​This version of the policy will be 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

The following CPT codes are Experimental/Investigational and have been added to Attachment A of this policy: 0508T, 0554T, 0555T, 0556T, 0557T, 0558T

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 Medicare Advantage Policy MA07.022 Capsule Endoscopy: 0651T

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

HCPCS CODES

The following HCPCS code has been termed (effective 1/1/2023) and has been removed from Attachment A of this policy: C1841 

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 MA00.005ae:
10/01/2022

​This version of the policy will be 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 Medicare Advantage Policy MA07.008 ​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

The following CPT code is Medically Necessary, and has been removed from Attachment A of this policy because its coverage position is communicated in Medicare Advantage Policy MA07.022 Capsule Endoscopy​: 91113

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 MA00.005ad:
07/01/2022

​This version of the policy will be 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​

The following service, which is represented by Unlisted code L8699, is Experimental/Investigational and has been added to Attachment B of this policy:
  • Electrical Continence Aid​

Revisions From MA00.005ac:
04/01/2022

​This version of the policy will be 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, 0322U​

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, 68841, 0042T, 0404T

The following service is represented by Unlisted code 33999, and has been removed from Attachment B of this policy because its Experimental/Investigational coverage position is communicated in Medicare Advantage policy MA11.040 Transcatheter Closure of Cardiac Septal Defects: 
  • Transmyocardial transcatheter closure of ventricular septal defect with implant 
​Unlisted code/service J3490 Secretin (SecreFlo)​ and has been removed from Attachment B of this policy.

Revisions From MA00.005ab:
01/10/2022

​This 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, 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: 0355T

REPLACED WITH: 91113​

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 MA00.005aa:
10/01/2021

​This 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 CPT code is Experimental/Investigational, and has been added to Attachment A of this policy: 0643T

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 is replaced by the following CPT code in Attachment A:

REMOVED: 0139U
​REPLACED WITH: 0263U

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

Revisions From MA00.005z:
07/12/2021

​This 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 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

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, 0645T, 0646T, 0647T, 0648T, 0649T, 0651T, 0652T, 0653T, 0654T, 0655T, 0656T, 0657T, 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 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 CPT code is considered Medically Necessary, and has been removed from Attachment A of this policy: 83698 

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 MA00.005y:
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, K1014, K1016, K1017, K1018, K1019

REMOVALS

The following CPT code is considered Medically Necessary, and has been removed from Attachment A of this policy: 0184T

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​​​

Revisions From MA00.005x:
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 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: 0085T
REPLACED WITH: 84999
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 From MA00.005w:
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, Q4150

The following CPT codes have been removed from Attachment A of this policy because their coverage position has been changed from Experimental/Investigational to eligible (effective 07/26/2020): 0596T, 0597T

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

Revisions From MA00.005v:
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, 0176U, 0178U

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

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

The following CPT codes are considered Medically Necessary and have been removed from Attachment A of this policy: 0446T, 0447T, 0448T
    The following HCPCS codes are Experimental/Investigational and have been added to Attachment A of this policy: C1748, C9759, C9764, C9765, C9766, C9767, Q4240, Q4241, Q4242

    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 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

    7/1/2026
    7/24/2026
    MA00.005
    Medical Policy Bulletin
    Medicare Advantage
    {"7647": {"Id":7647,"MPAttachmentLetter":"C","Title":"Experimental/Investigational services with a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code, that are reported for other services.","MPPolicyAttachmentInternalSourceId":10782,"PolicyAttachmentPageName":"69aa398b-78ba-46e2-9deb-a3b0d6ca56f4"},"7648": {"Id":7648,"MPAttachmentLetter":"B","Title":"Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.","MPPolicyAttachmentInternalSourceId":10783,"PolicyAttachmentPageName":"59ad7991-f6c1-4e6f-b6f8-4230ac4a278e"},"7649": {"Id":7649,"MPAttachmentLetter":"A","Title":"Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.","MPPolicyAttachmentInternalSourceId":10784,"PolicyAttachmentPageName":"65a73875-d77a-404c-9c06-7284b7d39636"},}
    No
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