Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 12.01.01av


Attachment:C

Policy #:12.01.01av

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

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 WITH SPECIFIC CURRENT PROCEDURAL TERMINOLOGY (CPT) OR HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES THAT ARE REPORTED FOR OTHER SERVICES

This list represents services that are considered E/I and are represented by a CPT or HCPCS code that can be reported for other services. The intent of this policy is to provide direction for the specific E/I services listed below. Because the CPT or HCPCS codes can be reported for other services, the code may not always represent a service that is considered E/I. Please review the applicable policy, if available, for detailed the coverage position involving the following E/I services.

Experimental/ Investigational Service
CPT / HCPCS Code
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
36902
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
36905
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
36907
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
37246
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
37247
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
37248
  • Liberation Procedure/Liberation Therapy
  • Balloon dilation to treat chronic cerebrospinal venous insufficiency (CCSVI) associated with multiple sclerosis
37249
  • InflammaDry®
  • Matrix Metalloproteinase-9 (MMP-9) when used as an inflammatory marker to detect dry eye disease
83516
  • Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira)
90875
  • Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira)
90876
  • Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira)
90901
  • Endoluminal imaging of coronary vessel or graft using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention
92978
  • Endoluminal imaging of coronary vessel or graft using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention
92979


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



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