Experimental-Investigational

Policy ID: Z-67-110

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: June 16, 2025

Revision Effective Date: September 01, 2025

Last Reviewed: September 04, 2025

Applies To: Commercial and Medicaid Expansion

Description

Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply ('intervention') that has been determined not to be medically effective for the condition being treated.

This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

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.

Procedure Codes

0017M

0018U

0064U

0243U

0247U

0248U

0249U

0445U

0459U

0479U

0482U

0490U

0491U

0492U

0511U

0512U

0513U

0524U

0525U

0542U

0545U

0546U

0547U

0548U

0550U

0551U

0554U

30468

30469

31242

31243

33267

33268

33269

33440

33900

33901

33902

33903

33904

36473

36474

36837

52284

53451

53452

53453

53454

57465

64913

66683

75571

82233

82234

84393

84394

90666

90667

90668

91022

92145

93895

93896

93897

93898

95919

96931

96932

96933

96934

96935

96936

97037

A4563

A4593

A4594

A9268

A9269

A9291

A9292

C1601

C1602

C1734

C1735

C1736

C1748

C1825

C1827

C1832

C1839

C8000

C8002

C8003

C8004

C9250

C9758

C9759

C9760

C9762

C9763

C9779

C9780

C9782

C9783

C9790

C9793

C9807

C9901

E0683

E0767

E1905

E2001

E3000

E3200

G0138

K1023

K1030

K1037

L8608

L8701

L8702

M0076

M0240

M0243

M0244

M0245

M0247

Q0035

Q0220

Q0221

Q0222

Q0240

Q0243

Q0244

Q0245

Q0247

S3902

S9025

Procedure code 0017M and 0018U are specific for Medicaid Expansion line of business and would be considered experimental/investigational.

Procedure Codes

0017M

0018U

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019

Added procedure codes 0543T; 0544T; 0545T; 0546T; 0547T; 0548T; 0549T: 0550T; 0551T; 0552T; 0553T; 0554T; 0555T; 0556T; 0557T; 0558T; 0559T; 0560T; 0561T; 0562T; 0085U; 0091U; 0092U; 0093U; 0095U; and
Removed procedure codes C9746; 0509T; 92273; 92274; S8930; and
Removed procedure codes 0006U; 0007U; 0011U; 0051U; 0054U; 0082U; 55874; and
Added procedure code C9250

Internal Medical Policy Committee 9-26-2019

Added procedure codes 0105U; 0106U; 0107U; 0108U; 0110U; 0121U; 0122U; 0123U; 0124U; 0125U; 0126U; 0127U; 0128U; and
Removed procedure codes 0011M; 0012M; 0013M; 0250T; 0251T; 0252T; 0288T; 0399T; 0040U; 0067U; 0068U; 0070U; 0071U; 0072U; 0073U; 0074U; 0075U; 0076U; 0078U; 0079U; Q4193; Q4194; Q4195; Q4196; and Q4197.

Internal Medical Policy Committee 1-22-2020 new code update

Added procedure codes 0139U; 0143U; 0144U; 0145U; 0146U; 0147U; 0148U; 0149U; 0569T; 0570T; 0581T; 0582T; 0564T; 0565T; 0566T; 0571T; 0572T; 0573T; 0574T; 0575T; 0576T; 0577T; 0578T; 0579T; 0580T; 0583T; 0563T; 0567T; 0568T; 64454; 64624; 64625; C1734; C1824; C1839; C1982; C2596; C9758; K1001; K1002; L2006; and
Removed procedure codes 0254T; 0016U; 0017U; 0019U; 0022U; 0023U; 0026U; 0027U; 0029U; 0030U; 0031U; 0032U; 0033U; 0034U; 0036U; 0053U; 0055U; 0056U; 0057U; 0069U; 0085U; and
Added procedure codes 0421T; 0563T; 0567T; 0568T; 0569T; 0570T; 0571T; 0581T; 0582T; and
Removed procedure codes 33274; 33275; and
Added procedure codes 0014M; 0163U; 0165U; 0166U; 0167U; 0168U; 0169U; 0170U; 0171U.

^{Internal Medical Policy Committee 7-22-2020 Coding update}

_Removed_{procedure code 64624;

and}
Added procedure Codes: 0174U; 0176U; 0178U; 0379T; 0596T; 0597T; 0598T; 0599T; 0600T; 0601T; 0602T; 0603T; 0604T; 0605T; 0606T; 0607T; 0608T; 0609T; 0610T; 0611T; 0612T; 0613T; 0615T; 0616T; 0617T; 0618T; 0619T; and
Removed procedure codes: 0594T; 0124U; 0125U; 0126U; 0127U; 0128U; and
Added Outpatient HCPCS (C codes) C1748; C9759; C9760; C9762; C9763; C9764; C9765; C9766; C9767.

^{Internal Medical Policy Committee 9-21-2020

Coding update
:}

Added Procedure codes: 0015M; K1006; K1009; K1010; K1011; and K1012; and
Added Outpatient HCPCS (C code) C9468; and
Removed procedure codes 0213T; 0214T; 0215T; 0216T;0217T; 0218T ; 0594T ; 0002U; 0012U; 0016U; 0017U; 0019U; 0021U; 0022U; 0023U; 0029U; 0030U; 0031U; 0032U; 0034U; 0035U; 0036U; 0038U; 0039U; 0041U; 0042U; 0043U; 0044U; 0058U; 0059U; 0061U; 0062U; 0063U; 0064U; 0065U; 0066U; 0069U; 0077U; 0080U; 0083U; 0091U; 0092U; 0093U; 0095U; 0105U; 0106U; 0107U; 0108U; 0110U; 0121U; 0122U; 0123U; 0139U; 0143U; 0144U; 0145U; 0146U; 0147U; 0148U; 0149U; 0150U; 0163U; 0164U; 0165U; 0166U; and 0167U

^{Internal Medical Policy Committee 11-19-2020 Coding update

:}

Removed Procedure codes: 31647; 31648; 31649; 31651; 0424T; 0425T; 0426T; 0427T; 0428T; 0429T; 0430T; 0431T; 0432T; 0433T; 0434T; 0435T; 0436T.

^{Internal Medical Policy Committee 1-19-2021

Coding update
:

Effective January 01, 2021}

_Added_{Procedure codes: 0620T; 0621T; 0622T; 0623T; 0624T; 0625T; 0626T; 0627T; 0628T; 0629T; 0630T; 0631T; 0632T; 0633T; 0634T; 0635T; 0636T; 0637T; 0638T; 0639T; 30468; 57465; 92229;

and}
^Removed^{Procedure codes}^{0111T; 0126T; 0381T; 0382T; 0383T; 0384T; 0385T; 0386T; 0396T; 0400T;0401T; 0405T; C1982;

and}
^Added^{Outpatient HCPCS (C codes) C1825; C9771; C9772; C9773; C9774; C9775.}

^{Internal Medical Policy Committee 3-17-2021 Coding Update:

Effective April 01, 2021}

Added Procedure codes: 0243U; 0247U; K1016; K1017; K1018; and K1019; and
Removed Procedure codes: K1010; K1011; and K1012.

Internal Medical Policy Committee 5-20-2021 Revision

Added statement 'if 22899 is billed with description of intracept procedure this would be E/I'; and
Added procedure code 22899; and
Added Outpatient HCPCS (C Code) C9752.

^{Internal Medical Policy Committee 7-22-2021

Coding Update:}

^Added^{Procedure Codes:0640T; 0641T; 0642T; 0643T; 0644T; 0645T; 0646T;}^{0648T; 0649T; 0652T; 0653T; 0654T; 0655T; 0656T;}^{0657T; 0658T; 0659T; 0660T; 0661T; 0662T; 0663T; 0248U; and 0249U.}

^{Internal Medical Policy Committee 9-21-2021

Coding update}

Added Procedure codes: C9779; C9780; and K1023; and
Removed Procedure Code: C9076

^{Internal Medical Policy Committee 11-23-2021 Coding Update-

Effective January 01, 2022}

Added^{_{procedure codes: 0207T; 0213T; 0214T; 0215T; 0216T; 0217T; 0218T; 0697T; 0698T; 33267; 33268; 33269; 42975; 53451; 53452; 53453; 53454; 68841;

and}}
^Added^{HCPCS (C code) C1832;}^and
^Removed^{Procedure codes: 0508T; 0554T; 0555T; 0556T; 0557T; 0558T.}

^{Internal Medical Policy Committee 1-20-2022 Coding update -

Effective March 7, 2022}

^Removed^{Procedure codes: 32994; 42975; and 0581T.}

^{Internal Medical Policy Committee 3-23-2022 Coding update

-Effective April 01, 2022}

^o^{Added
Procedure codes:

C9782; C9783; and K1030;

and

o

RemovedProcedure codes: 0412T; 0443T; 0582T; 0619T; 0655T; 92229; C2596; Q2055; and S8040.}

^{Internal Medical Policy Committee 5-24-2022 Coding update -

Effective July 04, 2022}

^o^{Added
several procedure codes-too many to list individually;

and}

^o^{RemovedProcedure codes: J9021; 64454; 64625; 0440T; 0441T; and 0442T.}

^{Internal Medical Policy Committee 7-21-2022 Coding update -

Various Effective Dates}

^o^{Removed
Procedure code 68841 -

Effective May 01, 2022}

^o^{Added
Procedure codes: 0717T; 0718T; 0719T; 0721T; 0722T; 0723T; 0724T; 0725T; 0726T; 0727T; 0728T; 0729T; 0730T; 0731T; 0732T; 0733T; 0734T; 0736T; 0737T; 0324U; 0325U; and 75571 -

Effective July 01, 2022}

^{o

Removed
Procedure code 64454; 64625; 90587; J9021

-

Effective July 01, 2022}

^o^Removed^{Procedure code E1629}^{-

Effective September 05, 2022}

^{Internal Medical Policy Committee 9-28-2022}^-^{Effective October 01, 2022}

^{o Removed}^{Procedure code J1952; 61736; 61737; 77089; 77090; 77091 & 77092}

^{Internal Medical Policy Committee 11-29-2022}^-^{Effective January 01, 2023}

_Removed_{procedure codes 0278T; K1016; K1017; K1018; K1019;

and}
_Added_{procedure codes Q0240; Q0243; Q0244; Q0245; Q0247; M0240; M0243; M0244; M0245; M0247;

and}
_Removed_{procedure codes 0475T; 0476T; 0477T; 0478T; 0487T; 0491T; 0492T; 0493T; 0499T;

and}
_Added_{procedure codes 30469; 36836; 36837; 33900; 33901; 33902; 33903; 33904; 69728; 69729; 69730; 95919; 0744T; 0745T; 0746T; 0747T; 0748T; 0765T; 0766T; 0767T; 0768T; 0769T; 0771T; 0772T; 0773T; 0774T; 0776T; 0777T; 0778T; 0779T; 0781T; 0782T; 0783T and C1827.}

^{Internal Medical Policy Committee}^{1-26-2023 -}^{Effective March 06, 2023}

Removed procedure codes 0408T; 0409T; 0410T; 0411T; 0413T; 0414T; 0417T; 0418T - these codes are now in policy S-278 Cardiac Contractility Modulation Therapy; and
Removed procedure codes 0415T; 0416T and C1824; and
Removed 0656T and 0657T - these codes are now in policy S-279 Vertebral Body Tethering; and
Added: 0001A; 0002A; 0003A; 0004A; 0011A; 0012A; 0013A; 0051A; 0052A; 0053A; 0054A; 0064A; 0071A; 0072A; 0073A; 0074A; 0081A; 0082A; 0083A; 0091A; 0092A; 0093A; 0094A; 0111A; 0112A, 0113A; 0173A; E1905; 90666; 90667; 90668; 91300; 91301; 91305; 91306; 91307; 91308; 91309; 91311; Q0220; Q0221; Q0222; Q0243; Q0244; Q0245; Q00247; and
Removed: 0470T; 0471T.

^{Internal Medical Policy}^Committee^{5-23-2023 -

Effective July 03, 2023}

Removed: procedure codes 0173A; 0707T; K1001; and
Added procedure codes 0014M; and 64913.

^{Internal Medical Policy Committee}^{7-26-2023-

Effective July 01, 2023}

^Removed^{procedure codes 0207T; 0330T; 0507T; 0563T; - these codes are now in policy Z-107 Intense Pulsed Light Therapy for the Treatment of Dry Eye Disease;

and}
^Removed^{procedure codes 69716; 69719; 69726; 69727; 69728; 69729; 69730;

and}
_Added_{procedure codes 0807T; and}_0808T.

^{Internal Medical Policy Committee}^{11-15-2023 - Coding update}

^Added^{procedure codes A9268; A9269; C9790; and C9788}^{-

Effective October 01, 2023}
^Added^{procedure codes A9291; and A9292}^{-

Effective January 01, 2024}

^{Internal Medical Policy Committee 1-16-2024 Coding update -

Effective January 01, 2024}

^Removed^{procedure codes 0499T; 0465T; 0533T; 0534T; 0535T; 0536T; 0641T; 0642T; 0768T; 0769T; C9771; C9788;

and}
^Added^{procedure codes 0784T; 0785T; 0811T; 0812T; 0815T; 0820T; 0821T; 0822T; 0858T; 0865T; 0866T; 31242; 31243; 52284; 67516; 92972; 97037; C1601; C1602; C9793; E2001; E3000;

and}
^Added^{section for Medicaid Expansion procedure code 0017M; and 0018U.}
^Removed^{procedure codes 0015M; 0174U; 0176U; 0178U; and 90759 -

Effective January 15, 2024}
^Removed^{procedure codes 0001A; 0002A; 0003A; 0004A; 0011A; 0012A; 0013A; 0051A; 0052A; 0052A; 0053A; 0054A; 0064A; 0071A; 0072A; 0073A, 0074A; 0081A; 0082A; 0083A; 0091A; 0092A; 0093A; 0094A; 0014M; 0111A; 0112A; 0113A; 0173A; 0497T; 0498T; 0324U; 0325U; 77091; 77092; 91300; 91301; 91305; 91306; 91307; 91308; 91309; 91311; C9752; E1905; K1006; and K1009.}
^Added^{procedure codes 0524T; 36473; and 36474 -

Effective March 04, 2024}

^{Internal Medical Policy Committee 3-19-2024 Revision with Coding update}

^{Effective May 06, 2024}
- ^Removed^{procedure codes 36836; 67516; 90689; and S2348.}
^{Effective April 01, 2024}^{- new codes}
- ^Added^{procedure codes 0443U; 0445U; A4593; A4594; A9293 G0138; and K1037.}

^{Internal Medical Policy Committee 5-14-2024 Coding update -

Effective July 1, 2024}

^Updated^{Policy Application}
^Removed^{Procedure Code 0202T and A9293.}

^{Internal Medical Policy Committee 7-16-2024 Coding update -

Effective July 01, 2024}

^Added^{July New Codes 0459U, 0869T, 0882T, 0883T, 0881T, 0875T, 0877T, 0878T, 0879T, 0880T, 0870T, 0871T, 0872T, 0873T, 0874T, 0884T, 0885T, 0886T, 0894T, 0895T, 0896T, C9901, 0897T, 0899T, 0900T, 0888T, 0898T, & 0893T}
^Removed^{Procedure Code C9790}

^{Internal Medical Policy Committee 9-17-2024}

^{Coding update -

Effective October 01, 2024}

_{^{Added
Procedure codes A4544; C8000; E0683; E0743; E0767; E3200; 0479U; 0482U; 0490U; 0491U; 0492U; 0511U; 0512U; and 0513U.}}

^{Coding update -

Effective November 04, 2024}
- ^{Added
  procedure code E1905; and}
- ^{Removed
  procedure code L2006}

^{Internal Medical Policy Committee 11-19-2024 Annual Review-no changes in criteria}

^{Internal Medical Policy Committee}^1-14-2025

Coding update - Effective January 01, 2025
- Removed deleted procedure codes 0553T; 0567T; 0616T; 0617T; and 0618T; and
- Added procedure codes 66683; 82233; 82234; 84393; 84394; 92137; 93896; 93897; 93898; 0524U; 0525U; 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; C1735; C1736; C8002; C8003; and C9807.
Annual Review - no changes in criteria - Effective March 03, 2025
- Updated Policy Application

Internal Medical Policy Committee 3-11-2025 Coding update - Effective May 05, 2025

Removed procedure codes 92137; 0568T; 0495U; 22899; and 0691T; and
Added procedure codes 0332T; 0614T; M0076; and S9025; and
*Special Note:With the arrival of April New codes from CMS post March IMPC. Procedure code(s) C8004; 0542U; 0545U; 0546U; 0547U; 0548U; 0550U; & 0551U have been added to March's IMPC with theEffective April 01, 2025.

Internal Medical Policy Committee 5-13-2025 Coding update - Effective July 01, 2025

Added procedure codes 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; and 0987T (July new codes)

Internal Medical Policy Committee 6-10-2025 Coding update - Effective July 07, 2025

o Removed procedure codes 0479T; 0480T; A4544; E0743; and

o Added procedure code C8004

Internal Medical Policy Committee 9-04-2025 Coding update - Effective September 01, 2025

Version 108
- Removed procedure codes 92972; C9764; C9765; C9766; C9767; C9772; C9773; C9774; C9775
Version 109
- Removed procedure codes 0545T; 0569T; 0570T; 0646T; 0897T; 0898T; 0899T; and 0900T.
Version 110

Removed 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; 0421T; 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; 0546T; 0547T; 0552T; 0559T; 0560T; 0561T; 0562T; 0564T; 0565T; 0566T; 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; 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; 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; 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; 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; 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; and 0987T (these T-codes are now part of new policy Z-111 Category III T Codes).

* Note: versions 108; 109; and 110 are combined and are effective September 01, 2025

Links

Reference (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Z-67-107

Section: Miscellaneous

Effective Date: November 01, 2019

Revised Date: May 13, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: June 10, 2025

Archived Date: August 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.

Policy Application

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

0017M

0018U

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

0421T

0422T

0437T

0439T

0443U

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

0564T

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

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

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

0064U

0243U

0247U

0248U

0249U

0445U

0459U

0479U

0482U

0490U

0491U

0492U

0511U

0512U

0513U

0524U

0525U

0542U

0545U

0546U

0547U

0548U

0550U

0551U

0554U

30468

30469

31242

31243

33267

33268

33269

33440

33900

33901

33902

33903

33904

36473

36474

36837

52284

53451

53452

53453

53454

57465

64913

66683

75571

82233

82234

84393

84394

90666

90667

90668

91022

92145

92972

93895

93896

93897

93898

95919

96931

96932

96933

96934

96935

96936

97037

A4563

A4593

A4594

A9268

A9269

A9291

A9292

C1601

C1602

C1734

C1735

C1736

C1748

C1825

C1827

C1832

C1839

C8000

C8002

C8003

C8004

C9250

C9758

C9759

C9760

C9762

C9763

C9764

C9765

C9766

C9767

C9772

C9773

C9774

C9775

C9779

C9780

C9782

C9783

C9790

C9793

C9807

C9901

E0683

E0767

E1905

E2001

E3000

E3200

G0138

K1023

K1030

K1037

L8608

L8701

L8702

M0076

M0240

M0243

M0244

M0245

M0247

Q0035

Q0220

Q0221

Q0222

Q0240

Q0243

Q0244

Q0245

Q0247

S3902

S9025

Procedure code 0017M and 0018U are specific for Medicaid Expansion line of business and would be considered experimental/investigational.

Procedure Codes

0017M

0018U

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019

Added procedure codes 0543T; 0544T; 0545T; 0546T; 0547T; 0548T; 0549T: 0550T; 0551T; 0552T; 0553T; 0554T; 0555T; 0556T; 0557T; 0558T; 0559T; 0560T; 0561T; 0562T; 0085U; 0091U; 0092U; 0093U; 0095U; and
Removed procedure codes C9746; 0509T; 92273; 92274; S8930; and
Removed procedure codes 0006U; 0007U; 0011U; 0051U; 0054U; 0082U; 55874; and
Added procedure code C9250

Internal Medical Policy Committee 9-26-2019

Added procedure codes 0105U; 0106U; 0107U; 0108U; 0110U; 0121U; 0122U; 0123U; 0124U; 0125U; 0126U; 0127U; 0128U; and
Removed procedure codes 0011M; 0012M; 0013M; 0250T; 0251T; 0252T; 0288T; 0399T; 0040U; 0067U; 0068U; 0070U; 0071U; 0072U; 0073U; 0074U; 0075U; 0076U; 0078U; 0079U; Q4193; Q4194; Q4195; Q4196; and Q4197.

Internal Medical Policy Committee 1-22-2020 new code update

Added procedure codes 0139U; 0143U; 0144U; 0145U; 0146U; 0147U; 0148U; 0149U; 0569T; 0570T; 0581T; 0582T; 0564T; 0565T; 0566T; 0571T; 0572T; 0573T; 0574T; 0575T; 0576T; 0577T; 0578T; 0579T; 0580T; 0583T; 0563T; 0567T; 0568T; 64454; 64624; 64625; C1734; C1824; C1839; C1982; C2596; C9758; K1001; K1002; L2006; and
Removed procedure codes 0254T; 0016U; 0017U; 0019U; 0022U; 0023U; 0026U; 0027U; 0029U; 0030U; 0031U; 0032U; 0033U; 0034U; 0036U; 0053U; 0055U; 0056U; 0057U; 0069U; 0085U; and
Added procedure codes 0421T; 0563T; 0567T; 0568T; 0569T; 0570T; 0571T; 0581T; 0582T; and
Removed procedure codes 33274; 33275; and
Added procedure codes 0014M; 0163U; 0165U; 0166U; 0167U; 0168U; 0169U; 0170U; 0171U.

^{Internal Medical Policy Committee 7-22-2020 Coding update}

_Removed_{procedure code 64624;

and}
Added procedure Codes: 0174U; 0176U; 0178U; 0379T; 0596T; 0597T; 0598T; 0599T; 0600T; 0601T; 0602T; 0603T; 0604T; 0605T; 0606T; 0607T; 0608T; 0609T; 0610T; 0611T; 0612T; 0613T; 0615T; 0616T; 0617T; 0618T; 0619T; and
Removed procedure codes: 0594T; 0124U; 0125U; 0126U; 0127U; 0128U; and
Added Outpatient HCPCS (C codes) C1748; C9759; C9760; C9762; C9763; C9764; C9765; C9766; C9767.

^{Internal Medical Policy Committee 9-21-2020

Coding update
:}

Added Procedure codes: 0015M; K1006; K1009; K1010; K1011; and K1012; and
Added Outpatient HCPCS (C code) C9468; and
Removed procedure codes 0213T; 0214T; 0215T; 0216T;0217T; 0218T ; 0594T ; 0002U; 0012U; 0016U; 0017U; 0019U; 0021U; 0022U; 0023U; 0029U; 0030U; 0031U; 0032U; 0034U; 0035U; 0036U; 0038U; 0039U; 0041U; 0042U; 0043U; 0044U; 0058U; 0059U; 0061U; 0062U; 0063U; 0064U; 0065U; 0066U; 0069U; 0077U; 0080U; 0083U; 0091U; 0092U; 0093U; 0095U; 0105U; 0106U; 0107U; 0108U; 0110U; 0121U; 0122U; 0123U; 0139U; 0143U; 0144U; 0145U; 0146U; 0147U; 0148U; 0149U; 0150U; 0163U; 0164U; 0165U; 0166U; and 0167U

^{Internal Medical Policy Committee 11-19-2020 Coding update

:}

Removed Procedure codes: 31647; 31648; 31649; 31651; 0424T; 0425T; 0426T; 0427T; 0428T; 0429T; 0430T; 0431T; 0432T; 0433T; 0434T; 0435T; 0436T.

^{Internal Medical Policy Committee 1-19-2021

Coding update
:

Effective January 01, 2021}

_Added_{Procedure codes: 0620T; 0621T; 0622T; 0623T; 0624T; 0625T; 0626T; 0627T; 0628T; 0629T; 0630T; 0631T; 0632T; 0633T; 0634T; 0635T; 0636T; 0637T; 0638T; 0639T; 30468; 57465; 92229;

and}
^Removed^{Procedure codes}^{0111T; 0126T; 0381T; 0382T; 0383T; 0384T; 0385T; 0386T; 0396T; 0400T;0401T; 0405T; C1982;

and}
^Added^{Outpatient HCPCS (C codes) C1825; C9771; C9772; C9773; C9774; C9775.}

^{Internal Medical Policy Committee 3-17-2021 Coding Update:

Effective April 01, 2021}

Added Procedure codes: 0243U; 0247U; K1016; K1017; K1018; and K1019; and
Removed Procedure codes: K1010; K1011; and K1012.

Internal Medical Policy Committee 5-20-2021 Revision

Added statement 'if 22899 is billed with description of intracept procedure this would be E/I'; and
Added procedure code 22899; and
Added Outpatient HCPCS (C Code) C9752.

^{Internal Medical Policy Committee 7-22-2021

Coding Update:}

^Added^{Procedure Codes:0640T; 0641T; 0642T; 0643T; 0644T; 0645T; 0646T;}^{0648T; 0649T; 0652T; 0653T; 0654T; 0655T; 0656T;}^{0657T; 0658T; 0659T; 0660T; 0661T; 0662T; 0663T; 0248U; and 0249U.}

^{Internal Medical Policy Committee 9-21-2021

Coding update}

Added Procedure codes: C9779; C9780; and K1023; and
Removed Procedure Code: C9076

^{Internal Medical Policy Committee 11-23-2021 Coding Update-

Effective January 01, 2022}

Added^{_{procedure codes: 0207T; 0213T; 0214T; 0215T; 0216T; 0217T; 0218T; 0697T; 0698T; 33267; 33268; 33269; 42975; 53451; 53452; 53453; 53454; 68841;

and}}
^Added^{HCPCS (C code) C1832;}^and
^Removed^{Procedure codes: 0508T; 0554T; 0555T; 0556T; 0557T; 0558T.}

^{Internal Medical Policy Committee 1-20-2022 Coding update -

Effective March 7, 2022}

^Removed^{Procedure codes: 32994; 42975; and 0581T.}

^{Internal Medical Policy Committee 3-23-2022 Coding update

-Effective April 01, 2022}

^o^{Added
Procedure codes:

C9782; C9783; and K1030;

and

o

RemovedProcedure codes: 0412T; 0443T; 0582T; 0619T; 0655T; 92229; C2596; Q2055; and S8040.}

^{Internal Medical Policy Committee 5-24-2022 Coding update -

Effective July 04, 2022}

^o^{Added
several procedure codes-too many to list individually;

and}

^o^{RemovedProcedure codes: J9021; 64454; 64625; 0440T; 0441T; and 0442T.}

^{Internal Medical Policy Committee 7-21-2022 Coding update -

Various Effective Dates}

^o^{Removed
Procedure code 68841 -

Effective May 01, 2022}

^{o

Removed
Procedure code 64454; 64625; 90587; J9021

-

Effective July 01, 2022}

^o^Removed^{Procedure code E1629}^{-

Effective September 05, 2022}

^{Internal Medical Policy Committee 9-28-2022}^-^{Effective October 01, 2022}

^{o Removed}^{Procedure code J1952; 61736; 61737; 77089; 77090; 77091 & 77092}

^{Internal Medical Policy Committee 11-29-2022}^-^{Effective January 01, 2023}

_Removed_{procedure codes 0278T; K1016; K1017; K1018; K1019;

and}
_Added_{procedure codes Q0240; Q0243; Q0244; Q0245; Q0247; M0240; M0243; M0244; M0245; M0247;

and}
_Removed_{procedure codes 0475T; 0476T; 0477T; 0478T; 0487T; 0491T; 0492T; 0493T; 0499T;

and}
_Added_{procedure codes 30469; 36836; 36837; 33900; 33901; 33902; 33903; 33904; 69728; 69729; 69730; 95919; 0744T; 0745T; 0746T; 0747T; 0748T; 0765T; 0766T; 0767T; 0768T; 0769T; 0771T; 0772T; 0773T; 0774T; 0776T; 0777T; 0778T; 0779T; 0781T; 0782T; 0783T and C1827.}

^{Internal Medical Policy Committee}^{1-26-2023 -}^{Effective March 06, 2023}

Removed procedure codes 0408T; 0409T; 0410T; 0411T; 0413T; 0414T; 0417T; 0418T - these codes are now in policy S-278 Cardiac Contractility Modulation Therapy; and
Removed procedure codes 0415T; 0416T and C1824; and
Removed 0656T and 0657T - these codes are now in policy S-279 Vertebral Body Tethering; and
Added: 0001A; 0002A; 0003A; 0004A; 0011A; 0012A; 0013A; 0051A; 0052A; 0053A; 0054A; 0064A; 0071A; 0072A; 0073A; 0074A; 0081A; 0082A; 0083A; 0091A; 0092A; 0093A; 0094A; 0111A; 0112A, 0113A; 0173A; E1905; 90666; 90667; 90668; 91300; 91301; 91305; 91306; 91307; 91308; 91309; 91311; Q0220; Q0221; Q0222; Q0243; Q0244; Q0245; Q00247; and
Removed: 0470T; 0471T.

^{Internal Medical Policy}^Committee^{5-23-2023 -

Effective July 03, 2023}

Removed: procedure codes 0173A; 0707T; K1001; and
Added procedure codes 0014M; and 64913.

^{Internal Medical Policy Committee}^{7-26-2023-

Effective July 01, 2023}

^Removed^{procedure codes 0207T; 0330T; 0507T; 0563T; - these codes are now in policy Z-107 Intense Pulsed Light Therapy for the Treatment of Dry Eye Disease;

and}
^Removed^{procedure codes 69716; 69719; 69726; 69727; 69728; 69729; 69730;

and}
_Added_{procedure codes 0807T; and}_0808T.

^{Internal Medical Policy Committee}^{11-15-2023 - Coding update}

^Added^{procedure codes A9268; A9269; C9790; and C9788}^{-

Effective October 01, 2023}
^Added^{procedure codes A9291; and A9292}^{-

Effective January 01, 2024}

^{Internal Medical Policy Committee 1-16-2024 Coding update -

Effective January 01, 2024}

^Removed^{procedure codes 0499T; 0465T; 0533T; 0534T; 0535T; 0536T; 0641T; 0642T; 0768T; 0769T; C9771; C9788;

and}
^Added^{procedure codes 0784T; 0785T; 0811T; 0812T; 0815T; 0820T; 0821T; 0822T; 0858T; 0865T; 0866T; 31242; 31243; 52284; 67516; 92972; 97037; C1601; C1602; C9793; E2001; E3000;

and}
^Added^{section for Medicaid Expansion procedure code 0017M; and 0018U.}
^Removed^{procedure codes 0015M; 0174U; 0176U; 0178U; and 90759 -

Effective January 15, 2024}
^Removed^{procedure codes 0001A; 0002A; 0003A; 0004A; 0011A; 0012A; 0013A; 0051A; 0052A; 0052A; 0053A; 0054A; 0064A; 0071A; 0072A; 0073A, 0074A; 0081A; 0082A; 0083A; 0091A; 0092A; 0093A; 0094A; 0014M; 0111A; 0112A; 0113A; 0173A; 0497T; 0498T; 0324U; 0325U; 77091; 77092; 91300; 91301; 91305; 91306; 91307; 91308; 91309; 91311; C9752; E1905; K1006; and K1009.}
^Added^{procedure codes 0524T; 36473; and 36474 -

Effective March 04, 2024}

^{Internal Medical Policy Committee 3-19-2024 Revision with Coding update}

^{Effective May 06, 2024}
- ^Removed^{procedure codes 36836; 67516; 90689; and S2348.}
^{Effective April 01, 2024}^{- new codes}
- ^Added^{procedure codes 0443U; 0445U; A4593; A4594; A9293 G0138; and K1037.}

^{Internal Medical Policy Committee 5-14-2024 Coding update -

Effective July 01, 2024}

^Updated^{Policy Application}
^Removed^{Procedure Code 0202T and A9293.}

^{Internal Medical Policy Committee 7-16-2024 Coding update -

Effective July 01, 2024}

^Added^{July New Codes 0459U, 0869T, 0882T, 0883T, 0881T, 0875T, 0877T, 0878T, 0879T, 0880T, 0870T, 0871T, 0872T, 0873T, 0874T, 0884T, 0885T, 0886T, 0894T, 0895T, 0896T, C9901, 0897T, 0899T, 0900T, 0888T, 0898T, & 0893T}
^Removed^{Procedure Code C9790}

^{Internal Medical Policy Committee 9-17-2024}

^{Coding update -

Effective October 01, 2024}

_{^{Added
Procedure codes A4544; C8000; E0683; E0743; E0767; E3200; 0479U; 0482U; 0490U; 0491U; 0492U; 0511U; 0512U; and 0513U.}}

^{Coding update -

Effective November 04, 2024}
- ^{Added
  procedure code E1905; and}
- ^{Removed
  procedure code L2006}

^{Internal Medical Policy Committee 11-19-2024 Annual Review-no changes in criteria}

^{Internal Medical Policy Committee}^1-14-2025

Coding update - Effective January 01, 2025
- Removed deleted procedure codes 0553T; 0567T; 0616T; 0617T; and 0618T; and
- Added procedure codes 66683; 82233; 82234; 84393; 84394; 92137; 93896; 93897; 93898; 0524U; 0525U; 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; C1735; C1736; C8002; C8003; and C9807.
Annual Review - no changes in criteria - Effective March 03, 2025
- Updated Policy Application

Internal Medical Policy Committee 3-11-2025 Coding update - Effective May 05, 2025

Removed procedure codes 92137; 0568T; 0495U; 22899; and 0691T; and
Added procedure codes 0332T; 0614T; M0076; and S9025; and
*Special Note:With the arrival of April New codes from CMS post March IMPC. Procedure code(s) C8004; 0542U; 0545U; 0546U; 0547U; 0548U; 0550U; & 0551U have been added to March's IMPC with theEffective April 01, 2025.

Internal Medical Policy Committee 5-13-2025 Coding update - Effective July 01, 2025

Added procedure codes 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; and 0987T (July new codes)

Internal Medical Policy Committee 6-10-2025 Coding update - Effective July 07, 2025

o Removed procedure codes 0479T; 0480T; A4544; E0743; and

o Added procedure code C8004

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