Our Member Services Representatives are unavailable Thursday, November 26, and Friday, November 27, due to the holiday. (Medium)

Miscellaneous Services

Section: Miscellaneous
Effective Date: January 01, 2020
Revised Date: November 14, 2019


This policy addresses those services considered to be miscellaneous and are typically not covered services.


ALL services on this policy are non-covered for ONE of the following reasons:

  • The service is considered experimental/investigational; or
  • The service is considered not medically necessary because it does not meet the definition of medically necessary; or
  • The service is a program exclusion/not a benefit; or
  • No professional service has been rendered.


The following services are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature:

  • Anal fistula plug
  • Bioimpedance spectroscopy for lymphedema
  • Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)
  • Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) (ImmuKnow®)
  • Electromagnetic Navigational Bronchoscopy (ENB) (e.g., SuperDimension Bronchus System, inReachTM System, iLogicTM Electromagnetic Navigation BronchoscopyTM, ig4TM EndoBronchial System)
  • Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
  • Endoscopic CryoSpray ablation of the esophagus
  • Ferriscan
  • Idiopathic Environmental Intolerance – treatment and testing (e.g., intracellular analysis of micronutrients, ALCAT, IVIg)
  • Multivariate analysis of patient-specific findings with quantifiable computer probability assessment, including report
  • Neuro-selective current perception threshold (CPT)/Sensory Nerve Conduction Test
  • Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or arterial, venous, or capillary glucose; and/or potassium concentration
  • Per-oral Endoscopic Myotomy (POEM) for treatment of esophageal achalasia
  • pH; exhaled breath condensate
  • Posturography (dynamic or static)
  • PreDx (Diabetes Risk Score)
  • Saliva test, hormone level; to assess preterm labor
  • Saliva test, hormone level; during menopause
  • Tenotomy of elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer’s elbow; percutaneous)
  • Thromboxane metabolite(s), including thromboxane if performed, urine
  • Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
  • InfraScanner Handheld Brain Hematoma Screening System For Early Detection of Intracranial Hemorrhage (ICH)

Procedure Codes

24357 29999 31627 43499 46707 53860 76498
81506 83987 84431 84999 86352 92548 92549
93702 99199 G0255 G9147 S2107 S2300 S3650

Not Medically Necessary

The following services are considered not medically necessary:

  • Defecography
  • Grenz Ray Therapy
  • Hair analysis
  • Lixiscope Service

Procedure Codes

P2031 74270 77499

Program Exclusion/Not a Benefit

A program exclusion/not a benefit is defined as EITHER ONE of the following:

  • Services generally not covered under the specified program(s); or
  • Groups define benefits, and determine coverage.

The following services are considered a program exclusion/not a benefit, and therefore non-covered:

  • Casted impressions for special shoes
  • EROS-Clitoral Therapy Device as a treatment of female sexual dysfunction
  • Hearing aid evaluation
  • Recreational or educational therapy (inpatient)

Procedure Codes

92590 92591 92592 92593 92594 92595 A9270

No Professional Service Rendered

When no professional service is rendered the service does not require direct patient care or contact.

The following services are considered no professional service rendered, and therefore non-covered:

  • Broken appointments
  • Glucola (glucose preparation)
  • Mileage for medical visit
  • Prolonged physician services without direct (face-to-face) contact
  • Team conferences
  • Telephone calls
  • Treatment planning and care coordination management for cancer initial treatment
  • Treatment planning and care coordination management for cancer established patient with a change of regimen

Procedure Codes

98966 98967 98968 99358 99359 99366 99367
99368 99441 99442 99443 99446 99447 99448
99449 A9270 S0353 S0354

Outpatient HCPCS (C Codes)