Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Services meeting ANY of the following criteria are considered experimental/investigational:
- The intervention does not have Food and Drug Administration (FDA) approval to be marketed for the specific relevant indication(s); or
- Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
- The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
- The intervention does not improve health outcomes; or
- The intervention is not proven to be applicable outside the research setting.
Procedure codes identified within this policy are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.
Note: This may not be an all-inclusive list as some T codes may have medically necessary criteria on other policies.
Procedure Codes
0100T
| 0174T
| 0175T
| 0198T
| 0200T
| 0201T
| 0213T
|
0214T
| 0215T
| 0216T
| 0217T
| 0218T
| 0219T
| 0220T
|
0221T
| 0222T
| 0263T
| 0264T
| 0265T
| 0266T
| 0267T
|
0268T
| 0269T
| 0270T
| 0271T
| 0272T
| 0273T
| 0308T
|
0329T
| 0331T
| 0332T
| 0333T
| 0338T
| 0339T
| 0342T
|
0358T
| 0378T
| 0379T
| 0422T
| 0437T
| 0439T
| 0444T
|
0445T
| 0469T
| 0472T
| 0473T
| 0484T
| 0485T
| 0486T
|
0488T
| 0489T
| 0490T
| 0505T
| 0506T
| 0515T
| 0516T
|
0517T
| 0518T
| 0519T
| 0520T
| 0521T
| 0522T
| 0523T
|
0524T
| 0525T
| 0526T
| 0527T
| 0528T
| 0529T
| 0530T
|
0531T
| 0532T
| 0541T
| 0542T
| 0543T
| 0544T
| 0545T
|
0546T
| 0547T
| 0552T
| 0559T
| 0560T
| 0561T
| 0562T
|
0565T
| 0566T
| 0569T
| 0570T
| 0571T
| 0572T
| 0573T
|
0574T
| 0575T
| 0576T
| 0577T
| 0578T
| 0579T
| 0580T
|
0583T
| 0596T
| 0597T
| 0598T
| 0599T
| 0600T
| 0601T
|
0602T
| 0603T
| 0604T
| 0605T
| 0606T
| 0607T
| 0608T
|
0609T
| 0610T
| 0611T
| 0612T
| 0613T
| 0614T
| 0615T
|
0620T
| 0621T
| 0622T
| 0623T
| 0624T
| 0625T
| 0626T
|
0627T
| 0628T
| 0629T
| 0630T
| 0631T
| 0632T
| 0633T
|
0634T
| 0635T
| 0636T
| 0637T
| 0638T
| 0639T
| 0640T
|
0643T
| 0644T
| 0645T
| 0646T
| 0648T
| 0649T
| 0652T
|
0653T
| 0654T
| 0658T
| 0659T
| 0660T
| 0661T
| 0662T
|
0663T
| 0664T
| 0665T
| 0666T
| 0667T
| 0668T
| 0669T
|
0670T
| 0672T
| 0673T
| 0674T
| 0675T
| 0676T
| 0677T
|
0678T
| 0679T
| 0680T
| 0681T
| 0682T
| 0683T
| 0684T
|
0685T
| 0686T
| 0687T
| 0688T
| 0689T
| 0690T
| 0691T
|
0692T
| 0693T
| 0694T
| 0695T
| 0696T
| 0697T
| 0698T
|
0700T
| 0701T
| 0704T
| 0705T
| 0706T
| 0708T
| 0709T
|
0717T
| 0718T
| 0719T
| 0721T
| 0722T
| 0723T
| 0724T
|
0725T
| 0726T
| 0727T
| 0728T
| 0729T
| 0730T
| 0731T
|
0732T
| 0733T
| 0734T
| 0736T
| 0737T
| 0740T
| 0741T
|
0744T
| 0745T
| 0746T
| 0747T
| 0748T
| 0764T
| 0765T
|
0766T
| 0767T
| 0771T
| 0772T
| 0773T
| 0774T
| 0776T
|
0777T
| 0778T
| 0779T
| 0781T
| 0782T
| 0783T
| 0784T
|
0785T
| 0791T
| 0793T
| 0794T
| 0805T
| 0806T
| 0807T
|
0808T
| 0810T
| 0811T
| 0812T
| 0815T
| 0820T
| 0821T
|
0822T
| 0857T
| 0858T
| 0865T
| 0866T
| 0869T
| 0870T
|
0871T
| 0872T
| 0873T
| 0874T
| 0875T
| 0877T
| 0878T
|
0879T
| 0880T
| 0881T
| 0882T
| 0883T
| 0884T
| 0885T
|
0886T
| 0888T
| 0893T
| 0894T
| 0895T
| 0896T
| 0897T
|
0898T
| 0899T
| 0900T
| 0901T
| 0902T
| 0903T
| 0904T
|
0905T
| 0906T
| 0907T
| 0908T
| 0909T
| 0910T
| 0911T
|
0912T
| 0913T
| 0914T
| 0915T
| 0916T
| 0917T
| 0918T
|
0919T
| 0920T
| 0921T
| 0922T
| 0923T
| 0924T
| 0925T
|
0926T
| 0927T
| 0928T
| 0929T
| 0930T
| 0931T
| 0932T
|
0933T
| 0934T
| 0935T
| 0936T
| 0937T
| 0938T
| 0939T
|
0940T
| 0941T
| 0942T
| 0943T
| 0944T
| 0946T
| 0948T
|
0949T
| 0951T
| 0952T
| 0953T
| 0954T
| 0955T
| 0956T
|
0957T
| 0958T
| 0959T
| 0960T
| 0961T
| 0962T
| 0963T
|
0967T
| 0968T
| 0969T
| 0970T
| 0971T
| 0972T
| 0973T
|
0974T
| 0975T
| 0976T
| 0977T
| 0978T
| 0979T
| 0980T
|
0981T
| 0982T
| 0983T
| 0984T
| 0985T
| 0986T
| 0987T
|
