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
|
