Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 12.01.01av


Attachment:A

Policy #:12.01.01av

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

Title:Experimental/Investigational Services


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

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

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



EXPERIMENTAL/INVESTIGATIONAL SERVICES REPRESENTED BY A SPECIFIC CPT/HCPCS CODE

This list is not all-inclusive and may not include services that were identified after the date of the policy. These services will be subject to review under the policy. Additions and deletions will be made as changes occur or if the experimental/investigational status of a service changes. The following list does not include those services that are sometimes covered based on criteria. More specific medical policies may be applicable.

CPT CODES

Code
Effective Date of E/I Coverage Position
19105
01/01/2007
20983
01/01/2015
22586
01/01/2013
31647
01/27/2020
31651
01/27/2020
33274
01/01/2019
33289
01/01/2019
43206
01/01/2013
46948
01/01/2020
53855
01/01/2010
53860
01/01/2011
58674
01/01/2017
62280
04/01/2018
62281
04/01/2018
62282
04/01/2018
62291
01/01/2017
62292
04/01/2018
64405
10/01/2015
64454
01/01/2020
64624
01/01/2020
64632
01/01/2019
64640
01/01/2019
64912
01/01/2018
64913
01/01/2018
77605
01/01/2017
81506
12/28/2011
82172
11/01/2016
82777
01/01/2013
83006
12/28/2011
83695
10/01/2016
83698
04/01/2015
83700
10/01/2016
83701
10/01/2016
83704
01/01/2016
83722
01/01/2019
86152
01/01/2013
86153
01/01/2013
86305
01/01/2010
86357
11/01/2016
86677
11/01/2016
87506
01/01/2015
87507
01/01/2015
87623
01/01/2015
88375
01/01/2013
90875
01/01/1997
90876
01/01/1997
91112
01/01/2014
91117
01/01/2011
91132
01/01/2001
91133
01/01/2001
92145
01/01/2015
92548
07/18/2017
92549
01/01/2020
93050
01/01/2016
93264
01/01/2019
93356
01/01/2020
93590
01/01/2017
93591
01/01/2017
93592
01/01/2017
93895
01/01/2015
96931
01/01/2016
96932
01/01/2016
96933
01/01/2016
96934
01/01/2016
96935
01/01/2016
96936
01/01/2016

Code
Effective Date of E/I Coverage Position
0010M
07/01/2015
0111T
07/01/2005
0126T
01/01/2006
0198T
01/01/2009
0202T
07/01/2009
0207T
01/01/2010
0219T
01/01/2010
0220T
01/01/2010
0221T
01/01/2010
0222T
01/01/2010
0263T
07/01/2011
0264T
07/01/2011
0265T
07/01/2011
0266T
07/01/2011
0267T
07/01/2011
0268T
07/01/2011
0269T
07/01/2011
0270T
07/01/2011
0271T
07/01/2011
0272T
07/01/2011
0273T
07/01/2011
0278T
01/01/2012
0290T
01/01/2012
0329T
07/01/2013
0330T
07/01/2013
0331T
07/01/2013
0332T
07/01/2013
0333T
07/01/2018
0335T
01/01/2014
0338T
01/01/2014
0339T
01/01/2014
0347T
07/01/2014
0348T
07/01/2014
0349T
07/01/2014
0350T
07/01/2014
0351T
07/01/2014
0352T
07/01/2014
0353T
07/01/2014
0354T
07/01/2014
0356T
07/01/2014
0358T
07/01/2014
0378T
01/01/2015
0379T
01/01/2015
0381T
01/01/2015
0382T
01/01/2015
0383T
01/01/2015
0384T
01/01/2015
0385T
01/01/2015
0386T
01/01/2015
0400T
01/01/2016
0401T
01/01/2016
0404T
01/01/2016
0405T
01/01/2016
0408T
01/01/2016
0409T
01/01/2016
0410T
01/01/2016
0411T
01/01/2016
0412T
01/01/2016
0413T
01/01/2016
0414T
01/01/2016
0415T
01/01/2016
0416T
01/01/2016
0417T
01/01/2016
0418T
01/01/2016
0419T
01/01/2016
0420T
01/01/2016
0422T
01/01/2016
0423T
01/01/2016
0424T
01/01/2016
0425T
01/01/2016
0426T
01/01/2016
0427T
01/01/2016
0428T
01/01/2016
0429T
01/01/2016
0430T
01/01/2016
0431T
01/01/2016
0432T
01/01/2016
0433T
01/01/2016
0434T
01/01/2016
0435T
01/01/2016
0436T
01/01/2016
0437T
07/01/2016
0440T
07/01/2016
0441T
07/01/2016
0442T
07/01/2016
0443T
07/01/2016
0444T
07/01/2016
0445T
07/01/2016
0451T
01/01/2017
0452T
01/01/2017
0453T
01/01/2017
0454T
01/01/2017
0455T
01/01/2017
0456T
01/01/2017
0457T
01/01/2017
0458T
01/01/2017
0459T
01/01/2017
0460T
01/01/2017
0461T
01/01/2017
0462T
01/01/2017
0463T
01/01/2017
0464T
01/01/2017
0465T
01/01/2017
0470T
07/01/2017
0471T
07/01/2017
0475T
07/01/2017
0476T
07/01/2017
0477T
07/01/2017
0478T
07/01/2017
0483T
01/01/2018
0484T
01/01/2018
0485T
01/01/2018
0486T
01/01/2018
0487T
01/01/2018
0489T
01/01/2018
0490T
01/01/2018
0491T
01/01/2018
0492T
01/01/2018
0493T
01/01/2018
0499T
01/01/2018
0506T
07/01/2018
0507T
07/01/2018
0511T
01/01/2019
0512T
01/01/2019
0513T
01/01/2019
0514T
01/01/2019
0515T
01/01/2019
0516T
01/01/2019
0517T
01/01/2019
0519T
01/01/2019
0520T
01/01/2019
0521T
01/01/2019
0522T
01/01/2019
0523T
01/01/2019
0525T
01/01/2019
0526T
01/01/2019
0527T
01/01/2019
0528T
01/01/2019
0529T
01/01/2019
0533T
01/01/2019
0534T
01/01/2019
0535T
01/01/2019
0536T
01/01/2019
0541T
01/01/2019
0542T
01/01/2019
0543T
07/01/2019
0544T
07/01/2019
0545T
07/01/2019
0546T
07/01/2019
0547T
07/01/2019
0548T
07/01/2019
0549T
07/01/2019
0553T
07/01/2019
0559T
07/01/2019
0560T
07/01/2019
0561T
07/01/2019
0562T
07/01/2019
0563T
01/01/2020
0567T
01/01/2020
0568T
01/01/2020
0571T
01/01/2020
0572T
01/01/2020
0574T
01/01/2020
0575T
01/01/2020
0576T
01/01/2020
0577T
01/01/2020
0578T
01/01/2020
0579T
01/01/2020
0581T
01/01/2020
0582T
01/01/2020
0583T
01/01/2020
0587T
01/01/2020
0589T
01/01/2020
0590T
01/01/2020
0021U
10/01/2017
0024U
01/01/2018
0025U
01/01/2018
0043U
04/01/2018
0044U
04/01/2018
0052U
07/01/2018
0061U
07/01/2018
0062U
10/01/2018
0063U
10/01/2018
0066U
10/01/2018
0080U
01/01/2019
0083U
01/01/2019
0092U
07/01/2019
0095U
07/01/2019
0105U
10/01/2019
0106U
10/01/2019
0107U
10/01/2019
0108U
10/01/2019
0119U
10/01/2019
0121U
10/01/2019
0122U
10/01/2019
0123U
10/01/2019
0124U
10/01/2019
0125U
10/01/2019
0126U
10/01/2019
0127U
10/01/2019
0128U
10/01/2019
0139U
01/01/2020
0165U
04/01/2020
0167U
04/01/2020


HCPCS CODES

Code
Narrative
Effective Date of E/I Coverage Position
A4563
Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each
01/01/2019
A4639
Replacement pad for infrared heating pad system, each
01/01/2003
A6000
Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card
01/01/2002
C1734
Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)
01/01/2020
C1886
Catheter extravascular tissue ablation, any modality, (insertable)
01/01/2012
C1824
Generator, cardiac contractility modulation (implantable)
01/01/2020
C1839
Iris prosthesis
01/01/2020
C1982
Catheter, pressure-generating, one-way valve, intermittently occlusive
01/01/2020
C2624
Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components
01/01/2015
C8937
Computer-aided detection, including computer algorithm analysis of breast mri image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation (list separately in addition to code for primary procedure)
01/01/2019
C9745
Nasal endoscopy, surgical; balloon dilation of eustachian tube
07/01/2017
C9749
Repair of nasal vestibular lateral wall stenosis with implant(s)
04/01/2018
C9751
Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisition(s) and 3-d rendering, computer-assisted, image-guided navigation, and endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]) and all mediastinal and/or hilar lymph node stations or structures and therapeutic intervention(s)
01/01/2019
C9752
Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum
01/01/2019
C9753
Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)
01/01/2019
C9756
Intraoperative near-infrared fluorescence lymphatic mapping of lymph node(s) (sentinel or tumor draining) with administration of indocyanine green (ICG) (List separately in addition to code for primary procedure)
07/01/2019
C9758
Blinded procedure for nyha class iii/iv heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study
01/01/2020
E0221
Infrared heating pad system
01/01/2002
E0231
Noncontact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover
01/01/2002
E0232
Warming card for use with the noncontact wound warming device and noncontact wound warming wound cover
01/01/2002
E0487
Spirometer, electronic, includes all accessories
01/01/2009
E0762
Transcutaneous electrical joint stimulation device system, includes all accessories
01/01/2006
G0281
Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care
04/01/2020
G0282
Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281
04/01/2020
G0295
Electromagnetic stimulation, to one or more areas, for wound care other than described in G0329 or for other uses
04/01/2020
G0329
Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care
04/01/2020
G0428
Collagen meniscus implant procedure for filling meniscal defects (e.g.,CMI, collagen scaffold, Menaflex)
04/01/2010
G9147
Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration
04/01/2010
J9285
Injection, olaratumab, 10 mg
10/01/2019
K1001
Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type
01/01/2020
K1004
Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories
01/01/2020
L2006
Knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated
01/01/2020
L8605
Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
01/01/2013
L8701
Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
01/01/2019
L8702
Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
01/01/2019
M0076
Prolotherapy
01/01/1986
Q4212
Allogen, per cc
10/01/2019
Q4213
Ascent, 0.5 mg
10/01/2019
Q4226
MyOwn skin, includes harvesting and preparation procedures, per square centimeter
10/01/2019
S2117
Subtalar Arthroereisis
07/01/2010
S3650
Saliva test, hormone level; during menopause
01/01/2000
S3652
Saliva test, hormone level; to assess preterm risk
01/01/2000
S3722
Dose optimization by area under the curve (AUC) analysis, for infusional 5-Fluorouracil
01/01/2012
S8080
Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical
01/01/2001
S9988
Services provided as part of a Phase 1 clinical trial
04/01/2004
S9990
Services provided as part of a Phase II clinical trial
01/01/2000
S9991
Services provided as part of a Phase III clinical trial
01/01/2000
S9994
Lodging costs (e.g., hotel charges) for clinical trial participant and one caregiver/companion
01/01/2000
S9996
Meals for clinical trial participant and one caregiver/companion
01/01/2000


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



2017 AmeriHealth.