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 |
0342T |
0358T |
0378T |
| 0379T |
0421T |
0422T |
0437T |
0439T |
0444T |
0445T |
| 0469T |
0472T |
0473T |
0484T |
0485T |
0486T |
0488T |
| 0489T |
0490T |
0505T |
0506T |
0515T |
0516T |
0517T |
| 0518T |
0519T |
0519T |
0520T |
0521T |
0522T |
0524T |
| 0525T |
0526T |
0527T |
0528T |
0529T |
0530T |
0531T |
| 0532T |
0541T |
0542T |
0543T |
0544T |
0545T |
0546T |
| 0547T |
0552T |
0559T |
0560T |
0561T |
0562T |
0564T |
| 0565T |
0566T |
0569T |
0570T |
0571T |
0572T |
0573T |
| 0574T |
0575T |
0576T |
0577T |
0578T |
0579T |
0580T |
| 0583T |
0594T |
0596T |
0597T |
0598T |
0599T |
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 |
| 0687T |
0688T |
0689T |
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 |
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 |
0870T |
0871T |
0872T |
0873T |
0874T |
0875T |
| 0877T |
0878T |
0879T |
0880T |
0881T |
0882T |
0883T |
| 0884T |
0885T |
0886T |
0888T |
0893T |
0894T |
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 |
