Experimental/Investigational | BCBSND (2024)

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; or

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 service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Services meetingANYof 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

Procedure code 22899 if billed with description of INTRACEPT PROCEDURE would be considered experimental/investigational

Procedure Code

22899

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

Procedure Code

Diagnosis Codes

Not applicable

Professional Statements and Societal Positions Guidelines

Not applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019

• Addedprocedure 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
• Removedprocedure codes C9746; 0509T; 92273; 92274; S8930
• Removedprocedure codes 0006U; 0007U; 0011U; 0051U; 0054U; 0082U; 55874
• Addedprocedure code C9250

Internal Medical Policy Committee 9-26-2019

• Addedprocedure codes 0105U; 0106U; 0107U; 0108U; 0110U; 0121U; 0122U; 0123U; 0124U; 0125U; 0126U; 0127U; 0128U;and
• Removedprocedure 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

• Addedprocedure 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
• Removedprocedure codes 0254T; 0016U; 0017U; 0019U; 0022U; 0023U; 0026U; 0027U; 0029U; 0030U; 0031U; 0032U; 0033U; 0034U; 0036U; 0053U; 0055U; 0056U; 0057U; 0069U; 0085U;and
• Addedprocedure codes 0421T; 0563T; 0567T; 0568T; 0569T; 0570T; 0571T; 0581T; 0582T;and
• Removedprocedure codes 33274; 33275;and
• Addedprocedure codes 0014M; 0163U; 0165U; 0166U; 0167U; 0168U; 0169U; 0170U; 0171U.

Internal Medical Policy Committee 7-22-2020 Coding update

• Removedprocedure code 64624;and
• Addedprocedure 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
• Removedprocedure codes: 0594T; 0124U; 0125U; 0126U; 0127U; 0128U;and
• AddedOutpatient 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
• AddedOutpatient HCPCS (C code) C9468;and
• Removedprocedure codes0213T; 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; 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 and C1982

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
• Removed Procedure codes: 0111T, 0126T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0396T, 0400T, 0401T, 0405T, C1982
• Outpatient HCPCS (Codes)
  • Added: 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;
• Removed Procedure codes: K1010, K1011 and K1012

Internal Medical Policy Committee 5-20-2021 Revision

• Addedstatement "if 22899 is billed with description of intracept procedure this would be E/I";and
• Addedprocedure code 22899;and
• AddedOutpatient 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, 0249U.

Internal Medical Policy Committee 9-21-2021 Coding update

• Added Procedure codes: C9779, C9780 and K1023
• 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
• Added HCPCS (C code) C1832
• 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

• Added Procedure codes: C9782, C9783 and K1030
• Removed Procedure codes: 0412T, 0443T, 0582T, 0619T, 0655T, 92229,C2596,Q2055 and S8040

Internal Medical Policy Committee 5-24-2022 Coding update - Effective July 04, 2022

• Added several procedure codes-too many to list individually.
• Removed Procedure codes: J9021, 64454, 64625, 0440T, 0441T, 0442T

Internal Medical Policy Committee 7-21-2022 Coding update - Various Effective Dates

• Removed Procedure code 68841 - Effective May 01, 2022
• 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
• Removed Procedure code 64454; 64625; 90587; J9021 - Effective July 01, 2022
• Removed Procedure code E1629 - Effective September 05, 2022

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

• Removed Procedure code J1952; 61736; 61737; 77089; 77090; 77091 & 77092

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

• Removedprocedurecodes 0278T; K1016; K1017; K1018; K1019;and
• Addedprocedure codes Q0240; Q0243; Q0244; Q0245; Q0247; M0240; M0243; M0244; M0245 and M0247
• Removedprocedure codes 0475T; 0476T; 0477T; 0478T; 0487T; 0491T; 0492T; 0493T; 0499T;and
• Addedprocedure 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

• Removedprocedure codes 0408T; 0409T; 0410T; 0411T; 0413T; 0414T; 0417T; 0418T - these code are now in policy S-278 Cardiac Contractility Modulation Therapy;and
• Removedprocedure codes 0415T; 0416T and C1824;and
• Removed0656T 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
• Addedprocedure codes 0014M, 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, 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, and 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

• Removedprocedure codes 36836; 67516; 90689; and S2348.

• Effective April 01, 2024- new codes
  • Addedprocedure codes 0443U; 0445U; A4593; A4594; A9293 G0138; and K1037.

Internal Medical Policy Committee 5-14-2024 Coding update -Effective July 1, 2024

• UpdatedPolicy Application
• RemovedProcedure Code 0202T and A9293; E1905 inadvertently fell off grid, was added back on.

Links

References (PDF)