Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 12.01.01av


Attachment:B

Policy #:12.01.01av

Description:Experimental/Investigational Services without 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 (E/I) SERVICES WITHOUT A SPECIFIC CURRENT PROCEDURAL TERMINOLOGY (CPT) OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODE

This list represents services that are considered E/I, but lack a specific CPT or HCPCS code. The intent of this policy is to provide direction for the specific E/I services listed below, that are not spoken to in a specific Company policy.

Because unlisted codes can be reported with many services, the unlisted codes below may be considered medically necessary when reported for other services. Please review the applicable policy, if available, for the detailed coverage position involving the following E/I services.


Experimental/Investigational Services
Unlisted Code
  • Microwave phased-array thermotherapy
  • Epithelial Cytologic Analysis of Nipple Aspirate Fluid from Breast Ductal Lavage, and/or Suction Collection
  • Suction Collection of Nipple Aspirate Fluid
  • Breast Ductal Lavage
  • Breast Duct Endoscopy
19499
88199
  • Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermotherapy guidance
19499
  • Use of the Savi Scout Surgical Guidance System
19499
  • Magnetically Controlled Growing Rod
  • Magnetic Expansion Control (MAGEC) System
22899
  • Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure)
22899
  • Injection of PRO-DENSE™
  • PRO-DENSE™
  • Bone Graft Substitute
  • Injectable Regenerative Graft
27299
  • Rhinophototherapy, intranasal application of ultraviolet and visible light, bilateral
30999
  • Confocal laser endomicroscopy (e.g., Cellvizio)
30999
31299
31599
31899
32999
42999
43499
43999
44799
45999
47999
48999
  • Fetal tissue transplantation
  • Embryonic tissue transplantation
  • Fetal mesencephalic transplantation
32999
33999
47399
48999
60699
64999
67299
  • Percutaneous Transmyocardial Revascularization (PTMR)
33999
  • Partial Left Ventriculectomy
  • Batista Procedure
33999
  • SENTINEL Cerebral Protection
  • Filterwire EZ Embolic Protection System
  • Embolic Protection Device (EPD)
  • Distal Occlusion Device
  • Proximal Occlusion Device
37799
  • Per-Oral Endoscopic Myotomy (POEM)
43499
  • Gastric Per Oral Endoscopic Myotomy (G-POEM)
  • Per Oral Pyloromyotomy (POP)
43999
  • Chromoendoscopy
44799
45399
  • Transanal radiofrequency of fecal incontinence
  • Secca System
46999
  • Anoscopy, with delivery of thermal energy to the muscle of the anal canal (e.g., for fecal incontinence)
  • Anoscopy with directed submucosal injection of bulking agent for fecal incontinence
46999
  • SURx
  • SURx TV (transvaginal) system
  • Transvaginal radiofrequency
  • Transurethral radiofrequency tissue remodeling
53899
  • Speculite
  • Speculoscopy
  • Speculoscopy without directed sampling
  • Speculoscopy with directed sampling
  • PapSure
58999
  • Motor function mapping using non-invasive navigated transcranial magnetic stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity
64999
  • Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s)
64999
  • Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period
64999
  • Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period permanent, with implantation of a pulse generator
64999
  • Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed
64999
  • Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed
64999
  • Spenopalatine ganglion (SPG) block
  • Use of the Tx360® Nasal Applicator
  • Use of the SphenoCath®
64999
  • Erector Spinae Plane (ESP) Block
  • Ultrasound-Guided Erector Spinae Plane Block
64999
  • Fistulization of sclera for glaucoma, through ciliary body
66999
  • Balloon dilation of eustachian tube
69799
  • iCAD VividLook
76498
  • Electrical impedance scanning of breast, bilateral (risk assessment for breast cancer)
76499
  • Dual energy x-ray absorptiometry (DEXA) for body composition study
76499
  • Near-infrared spectroscopy studies of lower extremity wounds (e.g., for oxyhemoglobin measurement)
76499
  • Avise PG
  • Avise 2.0
  • Avise SLE
  • Avise SLE+
  • Avise MTX
  • Avise HCQ
  • Avise SLE+CT 2.0
  • Avise SLE Prognostic
  • Avise Therapeutic Drug Monitoring
81599
84999
  • Direct measurement of Intermediate- Density Lipoproteins (IDL) (remnant lipoproteins)
84999
  • Holotranscobalamin quantitative
84999
  • MitoMet® Mitochondrial/Metabolic Microarray Analysis
  • BreastNextNext-Gen Cancer Panel
  • OvaNextNext-Gen Cancer Panel
  • ColoNext
  • CancerNextNext-Gen Cancer Panel
  • Counsyl Panel
  • Mitochondrial Disorders Panel
  • Whole Exome Sequencing
  • Genome-Wide (or Whole-Genome) Scanning/Sequencing (other than when specifically considered medically necessary in other Company medical policies)
  • Mitochondrial DNA (mtDNA) Whole-Genome Scanning/Sequencing
  • CorusCAD
  • 12 Gene Expression Assay
  • Oncotype DX
  • Oncotype DX Colon Cancer Assay
  • ColonPRS
  • Coloprint®
  • Genefx Colon®
  • OncoDefender-CRC (colon and rectal cancer)
  • Multigene expression assay for colon cancer
  • Gene expression assay for colon cancer
  • PathFinder TG
  • Topographic Genotyping with PathFinder TG
88199
88299
89240
  • Prostate PX® (Aureon Biosciences)
88399
  • Skin advanced glycation endproducts (AGE) measurement by multiwavelength fluorescent spectroscopy
88749
  • Sperm evaluation, Hyaluronan sperm binding test
89398
  • Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with high resolution esophageal pressure topography
  • Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion during high resolution esophageal pressure topography study (e.g., stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)
91299
  • Quantitative pupillometry with interpretation and report, unilateral or bilateral
92499
  • Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report
92499
  • Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report
  • Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and graphics only, without interpretation and report
  • Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; interpretation and report only
93799
  • Noninvasive measurement of left ventricular end diastolic pressure (LVEDP)
  • VeriCor, Left ventricular end diastolic pressure
  • VeriCor System
93799
  • Inert gas rebreathing for cardiac output measurement; during rest
  • Inert gas rebreathing for cardiac output measurement; during exercise
93799
  • Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; single, with interpretation and report
  • Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter – AV or VV delays only, with interpretation and report
  • Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter – AV or VV delays, with interpretation and report
93799
  • Intravascular catheter-based coronary vessel or graft spectroscopy (eg, infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure)
93799
  • Computerized database analysis of multiple cycles of digitized cardiac electrical data from two or more ECG leads, including transmission to a remote center, application of multiple nonlinear mathematical transformations, with coronary artery obstruction severity assessment
93799
  • Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluation(s), with interpretation and report
  • Continuous measurement of wheeze rate during treatment assessment or during sleep for documentation of nocturnal wheeze and cough for diagnostic evaluation 3 to 24 hours, with interpretation and report
94799
  • Thermogram; cephalic
  • Thermogram; peripheral
99199
  • Cerebral Thermal Perfusion Probe
  • QFlow 500 Probe
  • QFlow 500 Perfusion Monitoring System
  • Monitoring of regional cerebral blood flow (CBF) using an implanted cerebral thermal perfusion probe.
99199
  • Non-contact normothermic wound therapy
  • Warm-up active wound therapy
  • Warm-up wound therapy
  • Warm-up therapy system
99199
  • Clitoral Therapy Device (CTD)
  • EVA vacuum assist device for clitoral therapy
  • Urometrics, EROS clitoral therapy device
  • Vacuum therapy, clitoral therapy device
  • Vacuum therapy, female sexual dysfunction
E1399
  • Altered Auditory Feedback for Stuttering
E1399
  • Protonics Device
E1399
  • Pneumatic Thoracic Lumbosacral Orthosis;
  • Orthotrac Pneumatic Vest
E1399
  • Freespira®
E1399
  • Savi Scout Surgical Guidance System
E1399
  • Tx360® Nasal Applicator
  • SphenoCath®
E1399
  • Use of Autologous Fat as a bulking agent for the treatment of SUI due to ISD
  • Autologous Cartilage as a bulking agent for the treatment of SUI due to ISD
  • Polytetrafluoroethylene (Teflon®) as a bulking agent for the treatment of SUI due to ISD
  • Autologous Cellular Therapy (e.g., myoblasts, fibroblasts, muscle-derived stem cells or adipose-derived stem cells) for the treatment of SUI due to ISD
L8699
  • Powered Exoskeleton Devices for Lower Extremities
N/A
  • 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
N/A


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



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