Prior authorization request form Form

Medical Necessity Guidelines: Experimental, Investigational or Unproven Services

Last Review Date: April 24, 2026 
Number: MG.MM.AD.11

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All the aforementioned entities are affiliated companies under common control of EmblemHealth Inc Guideline EmblemHealth restricts coverage to those devices, treatments or procedures for which the safety and efficacy have been proven, and which are comparable or superior to conventional therapies. The plan defines the terms "investigational", "experimental" or “unproven” as the use of a service, procedure or supply that is not recognized by the Plan as standard medical care for the condition, disease, illness or injury being treated. A service, procedure or supply includes, but is not limited to the diagnostic service, treatment, facility, equipment, drug or device. A service is considered investigational, experimental or unproven, if any of the following criteria are met:

1. The services, procedures or supplies requiring Federal or other Governmental body approval, such as drugs and devices, do not have unrestricted market approval from the Food and Drug Administration (FDA) or final approval from any other governmental regulatory body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is not a substitute for final or unrestricted market approval.
2. There is insufficient or inconclusive medical and scientific evidence to permit the Plan to evaluate the therapeutic value of the service, procedure or supply. (Adequate evidence is defined as at least two documents of medical and scientific evidence that indicate that the proposed treatment is likely to be beneficial to the member.)
3. There is inconclusive medical and scientific evidence in peer-reviewed medical literature that the service, procedure or supply has a beneficial effect on health outcomes.
4. The service, procedure or supply under consideration is not as beneficial as any established alternatives.
5. There is insufficient information or inconclusive scientific evidence that, when used in a non- investigational setting, the service, procedure or supply has a beneficial effect on health outcomes or is as beneficial as any established alternatives.
6. Any device, medical treatment, supply or procedure for which safety and efficacy has not been established and proven is considered investigational (unproven) and is not considered to be medically necessary or appropriate.

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To determine whether a device, medical treatment or procedure is proven safe and effective, the following hierarchy of reliable evidence is used:

1. Published formal technology assessments and /or high-quality meta-analyses
2. Well-designed randomized studies published in credible, peer-reviewed literature
3. High quality case-control or cohort studies
4. Historical control studies

5. Reports of expert opinion from national professional medical societies or national medical policy organizations Limitations/Exclusions With respect to clinical studies, only those reports and articles, which contain scientifically valid data and published in the referred medical and scientific literature, shall be considered reliable evidence.
   Specifically, not included in the meaning of reliable evidence are reports, articles or statements by providers or groups of providers containing only abstracts, anecdotal evidence or personal professional opinions. Also, not included is the fact that a provider or a number of providers have elected to adopt a device, medical treatment or procedure as their personal treatment or procedure of choice or standard of practice. EmblemHealth adheres to Federal and state government program directives. Therefore, if there is a discrepancy between the overarching clinical coverage position and the member's benefits program, the benefits program will govern.

   Please see our related Clinical Trials Medical Policies: Commercial/Medicaid Clinical Trials/Experimental/Investigational Procedure/Treatments/Rare Disease Treatment — Commercial and Medicaid Medicare Clinical Trials — Medicare Commercial Table by CPT/HCPCS Code
   Medicare Table by CPT/HCPCS Code Revision History

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Commercial Plans The following CPT/HCPCS procedure codes are investigational and unproven and are therefore not covered. Experimental & Noncovered Investigational by CPT Code (Commercial Plans) 11950 11951 11952 11954 19105 20939 20983 22526 22527 22586 23700 24300 26340 27599 28035 28890 29893 30468 30469 31242 33289 33542 33548 34717 34718 41512 41530 43206 43252 43257 43284 43285 43290 43291 43889 49419 53451 53452 53453 53454 54240 58580 62290 62380 64555 64567 64595 64654 64655 64656 64657 64658 64659 64702 64704 64708 64712 64714 64722 64726 64727 64744 64910 64911 65765 65820 66683 69433 69705 69706 72295 75898 76498 76982 76983 77605 77615 77620 78811 78814 81173 81174 81195 81204 81230 81231 81232 81283 81291 81327 81328 81332 81335 81346 81354 81355 81383 81419 81434 81470 81471 81490 81493 81503 81504 81524 81525 81529 81535 81536 81540 81554 81558 82726 83006 83722 83789 83951 83987 84112 84378 86039 86152 86153 86200 86225 86235 86382 86431 87183 87801 88120 88121 88187 88323 88346 88350 88368 88375 89240 90867 90868 90869 91113 91132 91133 92145 92227 92449 92512 93050 93145 93146 93740 93895 94717 95012 96004 96904 96931 96932 96933 96934 96935 96936 97026 97039 97139 97607 97608 97610 99070 0002U 0003U 0004M 0006M 0007M 0007U 0008U 0009U 0010U 0011M 0011U 0012M 0013M 0014U 0015M 0016M 0017M 0018M 0019M 0019U 0020M 0021U 0024U 0025U 0029U 0030U 0031U 0032U 0034U 0035U 0036U 0038U 0041U 0042U 0045U 0047U 0048U 0051U 0052U 0053U 0054T 0054U 0055T 0055U 0058U 0059U 0060U 0061U 0062U 0063U 0066U 0067U 0068U 0069U 0071T 0072T 0075T 0076T 0077U 0078U 0079U 0080U 0082U 0083U 0086U 0087U 0088U 0089U

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Experimental & Noncovered Investigational by CPT Code (Commercial Plans) 0090U 0091U 0092U 0093U 0094U 0095T 0095U 0096U 0098T 0100T 0101T 0101U 0102T 0106T 0106U 0107T 0107U 0108T 0108U 0109T 0109U 0110T 0110U 0112U 0113U 0114U 0115U 0116U 0117U 0118U 0119U 0120U 0121U 0122U 0123U 0130U 0134U 0140U 0141U 0142U 0143U 0144U 0145U 0146U 0147U 0148U 0149U 0150U 0152U 0153U 0156U 0163U 0164T 0164U 0165T 0165U 0166U 0167U 0169U 0170U 0174T 0174U 0175T 0175U 0176U 0178U 0198T
0200T 0201T 0202T 0203U 0205U 0206U 0207T 0207U 0208T 0209T 0209U 0210T 0211T 0212T 0212U 0213T 0213U 0214T 0214U 0215T 0215U 0216T 0217T 0218T 0219T 0219U 0220T 0220U 0221T 0222T 0223U 0224U 0225U 0226U 0227U 0228U 0229U 0230U 0232T 0234T 0235T 0236T 0237T 0238T 0243U 0246U 0247U 0248U 0249U 0251U 0252U 0253U 0254U 0255U 0256U 0257U 0258U 0259U 0260U 0261U 0262U 0263T 0263U 0264T 0264U 0265T 0265U 0266U 0267U 0268U 0269U 0270U 0271U 0272U 0273U 0274T 0274U 0275U 0276U 0277T 0277U 0278T 0278U 0279U 0280U 0281U 0283U 0284U 0285U 0286U 0287U 0288U 0289U 0290U 0291U 0292U 0293U 0294U 0295U 0296U 0297U 0298U 0299U 0300U 0301U 0302U 0303U 0304U 0305U 0306U 0307U 0308U 0309U 0310U 0311U 0312U 0313U 0314U 0315U 0316U 0317U 0318U 0319U 0320U 0321U 0322U 0323U 0328U 0329T 0329U 0330T 0330U 0331T
0331U 0332T 0332U 0333T
0333U 0334U 0335T 0335U 0336U 0337U 0338U 0339U 0340U 0341U 0342T 0342U 0343U 0344U 0345U 0346U 0347T 0347U 0348T 0348U 0349T 0349U 0350T 0350U 0351T 0351U 0352T 0353T 0354T 0355T 0356U 0357U 0358T 0360U 0365U 0366U 0367U 0371U 0372U 0375U 0376U 0377T 0377U 0378T 0378U 0379T 0381U 0382U 0383U 0384U 0385U 0387U 0389U 0390U 0391U 0392U 0393U 0394U 0395T 0395U

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Experimental & Noncovered Investigational by CPT Code (Commercial Plans) 0396U 0397T 0398U 0399U 0401U 0403T 0404T 0404U 0406U 0408T
0409T 0410T 0411T 0412T 0413T 0414T 0415T 0415U 0416T 0417T 0418T 0419T 0419U 0420T 0422T 0423U 0424T 0425T 0426T 0427T 0428T 0429T 0430T 0431T 0432T 0433T 0434T 0435T 0436T 0437T 0439U 0440T 0440U 0441U 0442U 0443T 0443U 0444T 0445T 0445U 0446U 0447U 0452U 0453U 0454U 0456U 0457U 0458U 0459U 0462U 0464T 0465T 0465U 0466U 0467U 0468U 0469T 0469U 0470T 0470U 0471T 0471U 0472T 0472U 0473T 0474T 0475T 0476T 0477T 0478T 0479T 0479U 0480T 0480U 0481T 0482U 0483T 0483U 0484T 0484U 0485T 0486T 0486U 0487T 0488T 0489T 0490T 0490U 0491T 0491U 0492T 0492U 0493T 0494T 0495T 0495U 0496T 0496U 0497T 0497U 0498T 0498U 0499T 0500U 0501U 0502U 0503U 0504U 0505U 0506T 0506U 0507T 0507U 0508T 0510T 0510U 0511T 0511U 0512T 0512U 0513T 0513U 0514T 0514U 0515T 0515U 0516T 0517T 0517U 0518T 0518U 0519T 0519U 0520T 0520U 0521T 0522T 0522U 0523T 0524T 0524U 0525T 0525U 0526T 0526U 0527T 0527U 0528T 0528U 0529T 0530T 0531T 0531U 0532T 0533T 0534T 0535T 0535U 0536T 0541T 0541U 0542T 0542U 0543T 0544T 0545T 0545U 0546T 0546U 0547T 0547U 0548U 0552T 0554T 0555T 0556T 0556U 0557T 0557U 0558T 0558U 0559T 0559U 0560T 0560U 0561T 0561U 0562T 0563T 0563U 0564U 0565T 0565U 0566T 0566U 0568U 0569T 0569U 0570T 0570U 0572U 0573U 0574U 0575U 0576U 0577U 0578U 0579U 0580U 0581T 0581U 0582T 0583T 0584U 0586U 0587T 0587U 0588T 0588U 0589T 0589U 0590T 0590U 0591U 0593U 0594U 0595U 0596T 0596U 0597T 0597U 0598T 0598U 0599T 0599U 0600T 0600U 0601T 0601U 0602T 0602U 0603T 0603U 0604U 0605U 0606T 0606U 0607T 0607U 0608T 0608U 0609U 0610T 0610U

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Experimental & Noncovered Investigational by CPT Code (Commercial Plans) 0611T 0611U 0612T 0612U 0613T 0613U 0614U 0615T 0615U 0616U 0617U 0618U 0619U 0620T 0620U 0621T 0621U 0622T 0622U 0623U 0624U 0625U 0626U 0627T 0627U 0628T 0628U 0629T 0629U 0630T 0630U 0632T 0633T 0634T 0635T 0636T 0637T 0638T 0639T 0640T 0641T 0642T 0643T 0644T 0645T 0646T 0647T 0648T 0649T 0651T 0655T 0656T 0658T 0659T
0660T 0664T 0666T 0668T 0670T 0672T 0673T 0686T 0687T 0688T 0689T 0690T 0691T 0692T 0693T 0694T 0695T 0696T 0697T 0698T 0700T 0701T 0702T 0704T 0706T 0708T 0710T 0711T 0712T 0713T 0714T 0715T 0716T 0717T 0718T 0719T 0721T 0725T 0726T 0727T 0728T 0729T 0730T 0731T 0733T 0734T 0736T 0737T 0738T 0739T 0740T 0741T 0744T 0745T 0746T 0747T 0748T 0749T 0750T 0751T 0752T 0753T 0754T 0755T 0756T 0757T 0758T 0759T 0760T 0761T 0762T 0763T 0764T 0765T 0766T 0767T 0768T 0769T 0770T 0771T 0772T 0773T 0774T 0775T 0776T 0777T 0778T 0779T 0781T 0782T 0783T 0791T 0793T 0794T 0795T 0796T 0797T 0798T 0799T 0800T 0801T 0802T 0803T 0804T 0805T 0806T 0807T 0808T 0809T 0810T 0813T 0814T 0815T 0816T 0817T 0818T 0819T 0826T 0827T 0828T 0829T 0830T 0831T 0832T 0833T 0834T 0835T 0836T 0837T 0838T 0839T 0840T 0841T 0842T 0843T 0844T 0845T 0846T 0847T 0848T 0849T 0850T 0851T 0852T 0853T 0854T 0855T 0856T 0858T 0859T 0860T 0864T 0867T 0868T 0869T 0870T 0871T 0872T 0873T 0874T 0875T 0876T 0877T 0878T 0879T 0880T 0881T 0882T 0883T 0884T 0885T 0886T 0887T 0888T 0889T 0890T 0891T 0892T 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

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Experimental & Noncovered Investigational by CPT Code (Commercial Plans) 0925T 0926T 0927T 0928T 0929T 0930T 0931T 0932T 0933T 0934T 0935T 0936T 0937T 0938T 0939T 0940T 0941T 0942T 0943T 0944T 0945T 0946T 0947T 0948T 0949T 0950T 0951T 0952T 0953T 0954T 0955T 0956T 0957T 0958T 0959T 0960T 0961T 0962T 0963T 0964T 0965T 0966T 0967T 0968T 0969T 0970T 0971T 0972T 0973T 0974T 0975T 0976T 0977T 0978T 0979T 0980T 0981T 0982T 0983T 0984T 0985T 0986T 0987T 0988T 0989T 0990T 0991T 0992T 0993T 0996T 0997T 0998T 0999T 1000T 1001T 1002T 1003T 1004T 1005T 1006T 1007T 1008T 1009T 1010T 1011T 1012T 1013T 1014T 1015T 1016T 1017T 1018T 1020T 1022T 1023T 1024T 32994 A2001 A2002 A2004 A2005 A2006 A2007 A2008 A2009 A2010 A2011 A2012 A2013 A2014 A2015 A2016 A2017 A2018 A2019 A2020 A2021 A2022 A2023 A2024 A2025 A2026 A2027 A2028 A2029 A2030 A2031 A2032 A2033 A2034 A2035 A2036 A2037 A2038 A2039 A2040 A2041 A2042 A2043 A2044 A2045 A4335 A4337 A4341 A4342 A4541 A4542 A4543 A4544 A4545 A4558 A4563 A4575 A4593 A4594 A4638 A4639 A6000 A7049 A9272 A9292 A9586 C1608 C9790 C9791 C9792 C9809 C9810 E0218 E0221 E0231 E0232 E0236 E0490 E0491 E0492 E0493 E0530 E0711 E0715 E0716 E0721 E0732 E0733 E0734 E0735 E0736 E0737 E0738 E0739 E0743 E0761 E0762 E0765 E0767 E2120 E3000 E3200 G0555 H0047 J1817 J3490 J7030 J7040 J7050 K1007 K1028 K1029 K1030 K1035 K1036 L8605 L8608 L8699 L8701 L8702 M0235 M0236 Q1004 Q1005 Q4113 Q4114 Q4125 Q4139 Q4142 Q4143 Q4145 Q4149 Q4150 Q4162 Q4167 Q4171 Q4184 Q4185 Q4192 Q4193
Q4194 Q4198 Q4200 Q4201 Q4202 Q4204 Q4206 Q4227 Q4229 Q4230 Q4231 Q4232 Q4233 Q4234 Q4235 Q4236 Q4237 Q4238 Q4239 Q4241 Q4242 Q4244 Q4245 Q4247 Q4248 Q4249 Q4250 Q4254

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Experimental & Noncovered Investigational by CPT Code (Commercial Plans) Q4255 Q4259 Q4260 Q4261 Q4262 Q4263 Q4264 Q4265 Q4266 Q4267 Q4268 Q4269 Q4270 Q4271 Q4279 Q4285 Q4286 Q4289 Q4290 Q4291 Q4292 Q4293 Q4294 Q4295 Q4296 Q4297 Q4298 Q4299 Q4300 Q4301 Q4302 Q4303 Q4305 Q4306 Q4307 Q4308 Q4309 Q4310 Q4311 Q4312 Q4313 Q4314 Q4315 Q4316 Q4317 Q4318 Q4319 Q4320 Q4321 Q4322 Q4323 Q4324 Q4325 Q4326 Q4327 Q4328 Q4329 Q4330 Q4331 Q4332 Q4333 Q4334 Q4335 Q4336 Q4337 Q4338 Q4339 Q4340 Q4341 Q4342 Q4343 Q4344 Q4345 Q4346 Q4347 Q4348 Q4349 Q4350 Q4351 Q4352 Q4353 Q4354 Q4355 Q4356 Q4357 Q4358 Q4359 Q4360 Q4361 Q4362 Q4363 Q4364 Q4365 Q4366 Q4367 Q4368 Q4369 Q4370 Q4371 Q4372 Q4373 Q4375 Q4376 Q4377 Q4378 Q4379 Q4380 Q4382 Q4383 Q4384 Q4385 Q4386 Q4387 Q4388 Q4389 Q4390 Q4391 Q4392 Q4393 Q4394 Q4395 Q4396 Q4397 Q4398 Q4399 Q4400 Q4401 Q4402 Q4403 Q4404 Q4405 Q4406 Q4407 Q4408 Q4409 Q4410 Q4411 Q4412 Q4413 Q4414 Q4415 Q4416 Q4417 Q4418 Q4419 Q4420 Q4421 Q4422 Q4423 Q4424 Q4425 Q4426 Q4427 Q4428 Q4429 Q4431 Q4432 Q4433 Q4435 Q4436 Q4437 Q4438 Q4439 Q4440 S0800
S1030 S1031 S1090 S2117 S2140 S2300 S2348 S3650 S3722 S3800 S3852 S3900 S4024 S8037 S8080 S8130 S8131 S8930 S9055 S9090 V5299

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Medicare Plans The following CPT/HCPCS procedure codes are investigational and unproven and are therefore not covered. Experimental & Noncovered Investigational by CPT Code (Medicare Plans) 11950 11951 11952 11954 20939 22526 22527 22586 22860 23700 24300 28035 28890 29893 41512 43257 43284 49419 53451 53452 53453 53454 62290 62380 64702 64704 64708 64712 64714 64722 64726 64727 65765 65820 69433 72295 75898 76498 77605 77615 77620 81173 81174 81195 81204 81232 81234 81239 81252 81253 81254 81283 81289 81291 81328 81332 81346 81354 81383 81419 81430 81431 81434 81470 81471 81490 81493 81503 81524 81529 81535 81536 81558 82726 83006 83722 83789 83951 84112 84378 86039 86200 86225 86235 86382 87183 87801 88120 88121 88187 88323 88346 88350 88368 89240 90867 90868 90869 91113 92145 92449 93740 93895 96904 97026 97039 97139 99070 0001U 0002U 0003U 0007M 0007U 0008U 0009U 0010U 0011U 0012M 0013M 0014U 0016U 0017U 0019U 0020M 0021U 0024U 0025U 0029U 0030U 0031U 0032U 0034U 0035U 0036U 0038U 0040U 0041U 0042U 0043U 0044U 0051U 0053U 0054T 0054U 0055T 0055U 0058U 0059U 0060U 0061U 0062U 0063U 0066U 0067U 0068U 0069U 0071T 0071U 0072T 0072U 0073U 0074U 0075T 0075U 0076T 0076U 0077U 0078U 0079U 0082U 0083U 0084U 0086U 0087U 0088U 0091U 0092U 0093U 0094U 0095T 0095U 0096U 0098T 0100T 0101T 0102T 0106T 0106U 0107T 0107U 0108T 0108U 0109T 0109U 0110T 0110U 0112U 0113U 0114U 0115U 0116U 0117U 0118U 0119U 0120U 0121U 0122U 0123U 0129U 0130U 0133U 0136U 0137U 0138U 0140U 0141U 0142U 0143U 0144U 0145U 0146U 0147U 0148U 0149U 0150U 0152U 0153U 0156U

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Experimental & Noncovered Investigational by CPT Code (Medicare Plans) 0157U 0158U 0159U 0160U 0161U 0162U 0163U 0164T 0164U 0165T 0165U 0166U 0167U 0169U 0170U 0173U 0174T 0174U 0175T 0175U 0176U 0178U 0179U 0180U 0181U 0182U 0183U 0184U 0185U 0186U 0187U 0188U 0189U 0190U 0191U 0192U 0193U 0194U 0195U 0196U 0197U 0198T
0198U 0200T 0201T 0202T 0204U 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T 0218T 0219T 0220T 0221T 0222T 0223U 0225U 0232T 0234T 0235T 0236T 0237T 0238T 0243U 0246U 0247U 0263T 0264T 0265T 0274T 0277T 0278T 0287U 0312U 0329T 0330T 0331T
0332T 0333T
0335T 0342T 0347T 0348T 0349T 0350T 0351T 0352T 0353T 0353U 0354T 0354U 0355T 0357U 0358T 0358U 0360U 0365U 0366U 0367U 0371U 0372U 0375U 0376U 0377T 0377U 0378T 0378U 0379T 0381U 0382U 0383U 0384U 0385U 0387U 0389U 0390U 0391U 0393U 0394U 0395T 0395U 0396U 0397T 0398U 0399U 0401U 0402T 0403T 0404T 0406U 0408T
0409T 0410T 0411T 0412T 0413T 0414T 0415T 0416T 0417T 0418T 0419T 0420T 0422T 0424T 0425T 0426T 0427T 0428T 0429T 0430T 0431T 0432T 0433T 0434T 0435T 0436T 0437T 0439U 0440T 0440U 0441U 0442U 0443T 0443U 0444T 0445T 0445U 0446U 0447U 0450T 0452U 0453U 0454U 0456U 0457U 0458U 0459U 0462U 0464T 0465T 0465U 0466U 0467U 0468U 0469T 0469U 0470T 0470U 0471T 0471U 0472T 0472U 0473T 0474T 0475T 0476T 0477T 0478T 0479T 0479U 0480T 0480U 0481T 0482U 0483T 0483U 0484T 0484U 0485T 0486T 0486U 0487T 0488T 0489T 0490T 0490U 0491T 0491U 0492T 0492U 0493T 0494T 0495T 0495U 0496T 0496U 0497T 0497U 0498T 0498U 0499T 0500U 0501U 0502U 0503U 0504U 0505U 0506T 0506U 0507T 0507U 0508T 0510T 0510U 0511T 0511U 0512T 0512U 0513T 0513U 0514T 0514U 0515T 0515U 0516T

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Experimental & Noncovered Investigational by CPT Code (Medicare Plans) 0517T 0517U 0518T 0518U 0519T 0519U 0520T 0520U 0521T 0522T 0522U 0523T 0524U 0525T 0525U 0526T 0526U 0527T 0527U 0528T 0528U 0529T 0530T 0531T 0531u 0532T 0533T 0534T 0534u 0535T 0535u 0536T 0541T 0541u 0542T 0542u 0543T 0544T 0545T 0545u 0546T 0546u 0547T 0547u 0548u 0549U 0552T 0556U 0557U 0558U 0559T 0559U 0560T 0560U 0561T 0561U 0562T 0563T 0563U 0564U 0565T 0565U 0566T 0566U 0568U 0569T 0570T 0570U 0572U 0573U 0574U 0575U 0576U 0577U 0578U 0579U 0580U 0581T 0581U 0582T 0583T 0584U 0586U 0587T 0587U 0588T 0588U 0589T 0589U 0590T 0590U 0591U 0593U 0594U 0595U 0596T 0596U 0597T 0597U 0598T 0598U 0599T 0599U 0600T 0600U 0601T 0601U 0602T 0602U 0603T 0603U 0604U 0605U 0606T 0606U 0607T 0607U 0608T 0608U 0609U 0610T 0610U 0611T 0611U 0612T 0612U 0613T 0613U 0614U 0615T 0615U 0616U 0617U 0618U 0619U 0620T 0620U 0621T 0621U 0622T 0622U 0623U 0624U 0625U 0626U 0627T 0627U 0628T 0628U 0629T 0629U 0630T 0630U 0632T 0633T 0634T 0635T 0636T 0637T 0638T 0639T 0640T 0641T 0642T 0643T 0644T 0645T 0646T 0647T 0648T 0649T 0655T 0658T 0659T 0672T 0673T 0686T 0687T 0688T 0690T 0692T 0693T 0694T 0695T 0696T 0697T 0698T 0700T 0701T 0710T 0711T 0712T 0713T 0714T 0715T 0716T 0717T 0718T 0719T 0725T 0726T 0727T 0729T 0730T 0731T 0733T 0734T 0736T 0737T 0738T 0739T 0740T 0741T 0743T 0745T 0746T 0747T 0748T 0749T 0750T 0751T 0752T 0753T 0754T 0755T 0756T 0757T 0758T 0759T 0760T 0761T 0762T 0763T 0764T 0765T 0766T 0767T 0768T 0769T 0770T 0771T 0772T 0773T 0774T 0775T 0776T 0777T 0778T 0779T 0781T 0782T 0783T 0791T 0793T 0794T 0795T 0796T 0797T 0798T 0799T 0800T 0801T 0802T 0803T

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Experimental & Noncovered Investigational by CPT Code (Medicare Plans) 0804T 0805T 0806T 0807T 0808T 0809T 0810T 0814T 0815T 0816T 0817T 0818T 0819T 0826T 0827T 0828T 0829T 0830T 0831T 0832T 0833T 0834T 0835T 0836T 0837T 0838T 0839T 0840T 0841T 0842T 0843T 0844T 0845T 0846T 0847T 0848T 0849T 0850T 0851T 0852T 0853T 0854T 0855T 0856T 0858T 0859T 0860T 0864T 0867T 0868T 0869T 0870T 0871T 0872T 0873T 0874T 0875T 0876T 0877T 0878T 0879T 0880T 0881T 0882T 0883T 0884T 0885T 0886T 0887T 0888T 0889T 0890T 0891T 0892T 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 0945T 0946T 0947T 0948T 0949T 0950T 0951T 0952T 0953T 0954T 0955T 0956T 0957T 0958T 0959T 0960T 0961T 0962T 0963T 0964T 0965T 0966T 0967T 0968T 0969T 0970T 0971T 0972T 0973T 0974T 0975T 0976T 0977T 0978T 0979T 0980T 0981T 0982T 0983T 0984T 0985T 0986T 0987T 0988T 0989T 0990T 0991T 0992T 0993T 0996T 0997T 0998T 0999T 1000T 1001T 1002T 1003T 1004T 1005T 1006T 1007T 1008T 1009T 1010T 1011T 1012T 1013T 1014T 1015T 1016T 1017T 1018T 1020T 1022T 1023T 1024T 33542 33548 A2001 A2002 A2004 A2005 A2006 A2007 A2008 A2009 A2010 A2011 A2012 A2013 A2014 A2015 A2016 A2017 A2018 A2019 A2020 A2021 A2022 A2023 A2024 A2025 A2026 A2027 A2028 A2029 A2030 A2031 A2032 A2033 A2034 A2035 A2036 A2037 A2038 A2039 A4335 A4337 A4541 A4542 A4543 A4544 A4545 A4560 A4575 A4593 A4594 A4638 A4639 A6000 A7049 A9272 A9292 C9790 C9792 E0218 E0221 E0231

Page 13 of 22

Experimental & Noncovered Investigational by CPT Code (Medicare Plans) E0232 E0236 E0492 E0493 E0530 E0711 E0715 E0716 E0721 E0732 E0733 E0734 E0735 E0736 E0737 E0738 E0739 E0743 E0762 E0767 E2120 E3000 E3200 G0252 G0255 G0282 G0341 G0342 G0343 G0428 G0555 G9147 H0047 J1817 J3490 J7030 J7040 J7050 K1007 K1016 K1017 K1018 K1019 K1028 K1029 K1030 K1035 L7900 L7902 L8605 L8608 L8701 L8702 M0235 M0236 Q1004 Q1005 Q4113 Q4114 Q4125 Q4139 Q4142 Q4143 Q4145 Q4149 Q4150 Q4162 Q4167 Q4171 Q4184 Q4185 Q4191 Q4192 Q4193
Q4194 Q4198 Q4200 Q4201 Q4202 Q4204 Q4206 Q4227 Q4229 Q4230 Q4231 Q4232 Q4233 Q4234 Q4235 Q4236 Q4237 Q4238 Q4239 Q4241 Q4242 Q4244 Q4245 Q4247 Q4248 Q4249 Q4250 Q4254 Q4255 Q4259 Q4260 Q4261 Q4262 Q4263 Q4264 Q4265 Q4266 Q4267 Q4268 Q4269 Q4270 Q4271 Q4279 Q4285 Q4286 Q4289 Q4290 Q4291 Q4292 Q4293 Q4294 Q4295 Q4296 Q4297 Q4298 Q4299 Q4300 Q4301 Q4302 Q4303 Q4305 Q4306 Q4307 Q4308 Q4309 Q4310 Q4311 Q4312 Q4313 Q4314 Q4315 Q4316 Q4317 Q4318 Q4319 Q4320 Q4321 Q4322 Q4323 Q4324 Q4325 Q4326 Q4327 Q4328 Q4329 Q4330 Q4331 Q4332 Q4333 Q4334 Q4335 Q4336 Q4337 Q4338 Q4339 Q4340 Q4341 Q4342 Q4343 Q4344 Q4345 Q4346 Q4347 Q4348 Q4349 Q4350 Q4351 Q4352 Q4353 Q4354 Q4355 Q4356 Q4357 Q4358 Q4359 Q4360 Q4361 Q4362 Q4363 Q4364 Q4365 Q4366 Q4367 Q4368 Q4369 Q4370 Q4371 Q4372 Q4373 Q4375 Q4376 Q4377 Q4378 Q4379 Q4380 Q4382 Q4383 Q4384 Q4385 Q4386 Q4387 Q4388 Q4389 Q4390 Q4391 Q4392 Q4393 Q4394 Q4395 Q4396 Q4397 Q4398 Q4399 Q4400 Q4401 Q4402 Q4403 Q4404 Q4405 Q4406 Q4407 Q4408 Q4409 Q4410 Q4411 Q4412 Q4413 Q4414 Q4415 Q4416 Q4417 Q4420 Q4431 Q4432 Q4433 S4024 S8037 V5299

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Revision History: DATE REVISION 4/24/2026 Removed Codes effective 10/1/2026: • Commercial and Medicare: 69433

• Commercial only: 69705, 69706 4/24/2026 Added New Codes effective 4/01/2026: • Commercial and Medicare: 0614U, 0615U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U

• Commercial only: A2040, A2041, A2042, A2043, A2044, A2045, Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440 4/9/2026 Removed Code: • Commercial and Medicare: 27570 3/23/2026 Added Codes effective 7/15/2026: • Commercial: 0813T Correction to 2/27/2026 Revision History: • Commercial: 43290 and 43291 remain E&I 2/27/2026 Removed Codes effective 7/15/2026: • Commercial: 43210, 43290, 43291, 0675T, 0677T, 0679T, 0681T, 0683T, 0685T

• Commercial and Medicare: 0338T, 0339T, 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T 1/5/2026 Added New Codes effective 1/01/2026: • Commercial: 43889, 62330, 64567, 64654, 64655, 64656, 64657, 64658, 64659, 81354, 81524, 87183, 93145, 93146, 0600U, 0601U, 0602U, 0603U, 0604U, 0605U, 0606U, 0607U, 0608U, 0609U, 0610U, 0611U, 0612U, 0613U, 0988T, 0989T, 0990T, 0991T, 0992T, 0993T, 0996T, 0997T, 0998T, 0999T, 1000T, 1001T, 1002T, 1003T, 1004T, 1005T, 1006T, 1007T, 1008T, 1009T, 1010T, 1011T, 1012T, 1013T, 1014T, 1015T, 1016T, 1017T, 1018T, 1020T, 1022T, 1023T, 1024T, C1608, C9810, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433

• Medicare: 81354, 81524, 87183, 0600U, 0601U, 0602U, 0603U, 0604U, 0605U, 0606U, 0607U, 0608U, 0609U, 0610U, 0611U, 0612U, 0613U, 0988T, 0989T, 0990T, 0991T, 0992T, 0993T, 0996T, 0997T, 0998T, 0999T, 1000T, 1001T, 1002T, 1003T, 1004T,

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DATE REVISION 1005T, 1006T, 1007T, 1008T, 1009T, 1010T, 1011T, 1012T, 1013T, 1014T, 1015T, 1016T, 1017T, 1018T, 1020T, 1022T, 1023T, 1024T, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433 Removed Deleted Codes effective 1/01/2026: • Commercial: 0033U, 0042T, 0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, 0275T, 0361U, 0394T, 0508U, 0509U, 0544U, 0550U, 0551U, 0619T, 0623T, 0624T, 0625T, 0626T, 0631T, 0720T

• Medicare: 0033U, 0042T, 0135U, 0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, 0275T, 0361U, 0394T, 0508U, 0509U, 0544U, 0550U, 0551U, 0619T, 0623T, 0624T, 0625T, 0626T, 0631T, 0720T

11/20/2025 Removed Code effective 2/13/2026: • Commercial: 0450T 10/20/2025 Added New Codes effective 10/01/2025: • Commercial and Medicare: 0575U, 0576U, 0577U, 0578U, 0579U, 0580U, 0581U, 0584U, 0586U, 0587U, 0588U, 0589U, 0590U, 0591U, 0593U, 0594U, 0595U, 0596U, 0597U, 0598U, 0599U, A2036, A2037, A2038, A2039, M0235, M0236, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397 Removed Deleted Codes effective 10/01/2025: • Commercial and Medicare: 0450U, 0451U

Removed Codes effective 2/01/2026: • Commercial and Medicare: 36012, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249, 0043U, 0044U, 0358U, 0463U

9/18/2025 Added Codes effective 2/01/2026: • Commercial: 0019M, 0392U, 0404U, 0415U, 0419U, 0423U

Removed Codes effective 2/01/2026: • Commercial: 33274, 33275

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DATE REVISION 8/18/2025

Added Codes effective 7/1/2025: • Commercial: 0556U, 0557U, 0558U, 0559U, 0560U, 0561U, 0563U, 0564U, 0565U, 0566U, 0568U, 0569U, 0570U, 0572U, 0573U, 0574U, 0948T, 0949T, 0950T, 0951T, 0952T, 0953T, 0954T, 0955T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0963T, 0964T, 0965T, 0966T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0977T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, 0987T, Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382

• Medicare: 0556U, 0557U, 0558U, 0559U, 0560U, 0561U, 0563U, 0564U, 0565U, 0566U, 0568U, 0570U, 0572U, 0573U, 0574U, 0948T, 0949T, 0950T, 0951T, 0952T, 0953T, 0954T, 0955T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0963T, 0964T, 0965T, 0966T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0977T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, 0987T, Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382 Removed Deleted Codes effective 7/1/2025: • Commercial: 0240U, 0241U • Commercial and Medicare: 0370U, 0373U, 0374U Removed Codes effective 1/1/2026: • Commercial and Medicare: 0064U, 0065U, 0359U, 0521U, 88313 • Commercial: 0210U, 0455U, 0537U • Medicare: 0171U Removed Following Codes: • Commercial and Medicare: 0359U, 23470, 23472 6/26/2025 Removed following three codes for Medicare only: • 0402U effective 10/1/2023 • 0455U effective 7/1/2024 • 0537U effective 4/1/2025 5/9/2025 “Limitations/Exclusions” section updated to include hyperlinks to related Clinical Trial Medical Policies 5/1/2025 Removed Codes effective 8/15/2025: • Commercial: 64628, 64629 • Medicare: 64629 Code removed from Commercial as correction: 0364U

Page 17 of 22

DATE REVISION 4/25/2025 Added Codes effective 8/01/2025: • Commercial: 26340, 64595, 64744, 65765, 76982 and 76983 • Medicare: 65765 4/14/2025 Added Codes effective 4/01/2025: • Commercial and Medicare: 0531U, 0534U, 0535U, 0537U, 0541U, 0542U, 0544U, 0545U, 0546U, 0547U, 0548U, 0549U, 0550U, 0551U, A2030, A2031, A2032, A2033, A2034, A2035, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, S4024 4/14/2025 Added: • Commercial: 0468U 3/14/2025 Added Codes effective 1/01/2025: • Commercial: A4545, E0737, Q4310 • Medicare: 81490, A4545, E0737, Q4310 Removed Codes effective 1/01/2025: • Commercial: 0493U, 81243, 81455, 88112 • Medicare: 0340U, 0493U, 81243, 86140, 86352 3/05/2025 Correction: • Corrected code 0609T to 0690T in Commercial and Medicare tables 2/03/2025 Added New Codes effective 1/01/2025: • Commercial: 66683, 81195, 81558, 0521U, 0522U, 0524U, 0525U, 0526U, 0527U, 0528U, 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, 0945T, 0946T, 0947T, C9809, G0555, Q4346, Q4347, Q4348, Q4349, Q4350 and Q4351

• Medicare: 81195, 81558, 0521U, 0522U, 0524U, 0525U, 0526U, 0527U, 0528U, 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, 0945T, 0946T, 0947T, G0555, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352 and Q4353 Removed Deleted Codes effective 1/01/2025: • Commercial: 0398T, 0553T, 0564T, 0567T and 0568T • Medicare: 0553T, 0564T, 0567T and 0568T

Page 18 of 22

DATE REVISION 2/03/2025 Removed effective 1/01/2025: • Commercial: 81541 2/03/2025 Added: • Commercial and Medicare: 0479U, 0480U, 0482U, 0483U, 0484U, 0486U, 0490U, 0491U, 0492U, 0493U, 0495U, 0496U, 0497U, 0498U, 0500U, 0501U, 0502U, 0503U, 0504U, 0505U, 0506U, 0507U, 0508U, 0509U, 0510U, 0511U, 0512U, 0513U, 0514U, 0515U, 0517U, 0518U, 0519U, 0520U, A2027, A2028, A2029, A4543, A4544, E0715, E0716, E0721, E0743, E0767, E3200, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, and Q4345 7/13/2024 Codes Added and Removed: • Commercial: o Added: A2027, A2028, A2029, A4544, E0743 o Removed: 81552, 89398, 0352U • Medicare: o Added: 81529, A2027, A2028, A2029, A4544, E0743 o Removed: 89398 7/13/2024 Codes Added and Removed: • Commercial: o Added: 89398, 0020M, 0450U, 0451U, 0452U, 0453U, 0454U, 0455U, 0456U, 0457U, 0458U, 0459U, 0462U, 0463U, 0465U, 0466U, 0467U 0469U, 0470U, 0471U, 0472U, 0867T, 0868T, 0869T, 0870T, 0871T, 0872T, 0873T, 0874T, 0875T, 0876T, 0877T, 0878T, 0879T, 0880T, 0881T, 0882T, 0883T, 0884T, 0885T, 0886T, 0887T, 0888T, 0889T, 0890T, 0891T, 0892T, 0893T, 0894T, 0895T, 0896T, 0897T, 0898T, 0899T, 0900T, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333 o Removed: 0204U, 0353U, 0354U, K1016, K1017, K1018, K1019 • Medicare: o Added: 89398, 0020M, 0450U, 0451U, 0452U, 0453U, 0454U, 0455U, 0456U, 0457U, 0458U, 0459U, 0462U, 0463U, 0465U, 0466U, 0467U 0469U, 0470U, 0471U, 0472U, 0867T, 0868T, 0869T, 0870T, 0871T, 0872T, 0873T, 0874T, 0875T, 0876T, 0877T, 0878T, 0879T, 0880T, 0881T, 0882T, 0883T, 0884T, 0885T, 0886T, 0887T, 0888T, 0889T, 0890T, 0891T, 0892T, 0893T, 0894T, 0895T, 0896T, 0897T, 0898T, 0899T, 0900T, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333 o Removed: 0204U, 0353U, 0354U, K1016, K1017, K1018, K1019, 0524T

Page 19 of 22

DATE REVISION 4/29/2024 Codes Added and Removed: • Commercial: o Added: 0010U, 0036U, 0440U, 0441U, 0442U, 0443U, 0445U, 0446U, 0447U, A2026, A4594, E0736, E0738, E0739, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310 o Removed: 61736, 61737, 81520, 81521, 81241, 81256, 86140, 86352,93702, 0662T, 0663T • Medicare: o Added: 0010U, 0440U, 0441U, 0442U, 0443U, 0445U, 0446U, 0447U, A2026, A4594, E0736, E0738, E0739, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310 o Removed: 81241, 81256, 88112, 81284, 81256, 88112, 81284, 81285, 81286, 81520, 81521, 0023U, 0662T, 0663T 1/24/2024 Codes Added and Removed: • Commercial: o Added: 58580, 0814T, 0815T, 0816T, 0817T, 0818T, 0819T, 0826T, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 0858T, 0856T, 0858T, 0859T, 0860T, 0864T, 0014U, 0353U, 0354U A4541, A4542, E0492, E0493, E0530, E0732, E0733, E0734, E0735, E3000, Q4279, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303 o Removed: 21499, 76120, 76125, 20985, S2900, 0013U • Medicare: o Added: 0814T, 0815T, 0816T, 0817T, 0818T, 0819T, 0826T, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 0858T, 0856T, 0858T, 0859T, 0860T, 0864T, 0014U, 0353U, 0354U A4541, A4542, E0492, E0493, E0530, E0732, E0733, E0734, E0735, E3000, Q4279, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303 10/31/2023 Codes Added and Removed: • Commercial: o Added: K1028, K1029, S8037 • Medicare: o Added: A2022, A2023, A2024, A2025, A9292, A9272, C9790, C9792, Q4285, Q4286, 0406U o Removed: 20560, 20561

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DATE REVISION 10/1/2023 Codes Added and Removed: • Commercial: o Added: 0406U, 97607, 97608, A2022, A2023, A2024, A2025, A9292, C9790, C9791, C9792, E0490, E0491, K1036, Q4285, Q4286 o Removed: 0324U, 0325U, • Medicare: o Added: A2022, A2023, A2024, A2025, A9292, A9272, C9790, C9792, Q4285, Q4286, 0406U o Removed: 20560, 20561

7/19/2023 Codes Added and Removed: • Commercial: o Added: 43290, 43291, 0508T, 0387U, 0389U, 0390U, 0391U, 0393U, 0394U, 0395U, 0396U, 0398U, 0399U, 0101U, 0791T, 0793T, 0794T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0805T, 0806T, 0807T, 0808T, 0809T, 0810T o Removed: 0163T, 82948

• Medicare: o Added: 0387U, 0393U, 0394U, 0395U, 0399U, 0791T, 0793T, 0794T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0805T, 0806T, 0807T, 0808T, 0809T, 0810T o Removed: 0163T

5/31/2023 Codes Removed: • Commercial: o Removed: 36473, 36474, 37500, 37799, 95803

4/28/2023 Codes Added and Removed: • Commercial: o Added: A2011, A2012 o Removed: 47399, 64405, 81200, 81205, 81209, 81242, 81244, 81250, 81251, 81255, 81257, 81260, 81271, 81274, 81290, 81330, 81361, 81362, 81363, 81364, 81400, 81402, 81407, 81408, 81443, 81435, 82397, 89253, 96365, 96366, L8680, L8682, L8683, S3854 • Medicare: o Added: 0596T, 0597T, A2011, A2012 o Removed: 47399, 64405, 64628, 81200, 81205, 81209, 81242, 81244, 81250, 81251, 81255, 81257, 81260, 81271, 81274, 81290, 81330, 81361, 81362, 81363, 81364, 81400, 81402, 81407, 81408, 81443, 81435, 82397, 89253, 96365, 96366, L8680, L8682, L8683, S3854

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DATE REVISION 3/31/2023 Codes Added and Removed: • Commercial: o Added: 0364U, 0365U, 0366U, 0367U, 0370U, 0371U, 0372U, 0373U, 0374U, 0375U, 0376U, 0377U, 0378U, 0381U, 0382U, 0383U, 0384U, 0385U, A2014, A2015, A2016, A2017, A2018, A2019, A2020, A2021, A7049, E0711, G0281, G0329, K1035, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271 o Removed: 0105U, 81220, 81221, 81222, 81223, 81224, 85576, K1006, Q4158, Q4176, Q4179, Q4228
• Medicare: o Added: 0365U, 0366U, 0367U, 0370U, 0371U, 0372U, 0373U, 0374U, 0375U, 0376U, 0377U, 0378U, 0381U, 0382U, 0383U, 0384U, 0385U, A2014, A2015, A2016, A2017, A2018, A2019, A2020, A2021, A4560, A7049, E0711, K1035, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271 o Removed: 0105U, 81220, 81221, 81222, 81223, 81224, 85576, K1006, Q4158, Q4176, Q4179, Q4228 2/17/2023 Codes Added and Removed: • Commercial: o Added: 0721T o Removed: 0202U, 43270, 81238, Q4130, Q4189, Q4240, Q4246 • Medicare: o Removed: 43270, 0046U, 0049U, 0050U, 0202U, Q4130, Q4189, Q4240, Q4246

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DATE REVISION 12/29/2022 Codes added that will be effective 1/1/2023: • Commercial and Medicare: o 0357U, 0358U, 0359U, 0360U, 0361U, 0738T, 0739T, 0740T, 0741T, 0745T, 0746T, 0747T, 0748T, 0749T, 0750T, 0751T, 0752T, 0753T, 0754T, 0755T, 0756T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T, 0764T, 0765T, 0766T, 0767T, 0768T, 0769T, 0770T, 0771T, 0772T, 0773T, 0774T, 0775T, 0776T, 0777T, 0778T, 0779T, 0781T, 0782T, 0783T • Commercial: o 0744T, 30469 • Medicare: o 22860, 0743T Code added:
• Commercial: o 0047U – Commercial coverage reversed Codes removed:
• Commercial: o 88360 – Covered for Commercial o 0500T – Covered for preventive services
• Medicare: o 0047U - Covered for Medicare o 0089U – Covered for Medicare o 81541 – Covered for Medicare o 88360 - Covered for Medicare Removed the Medicaid table 10/31/2022 Codes added that will be effective 2/15/2023: • Commercial, Medicare, and Medicaid: o 81541, 0003U, 0008U, 0009U, 0013U 0014U, 0019U, 0029U, 0030U, 0032U, 0033U, 0047U, 0053U, 0055U, 0067U, 0069U, 0078U, 0089U, 0109U, 0112U, 0113U, 0114U, 0118U, 0120U, 0152U, 0153U, 0156U, 0169U, 0170U, 0175U, 0203U, 0204U, 0205U, 0220U, 0228U, 0229U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0266U, 0285U, 0286U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0311U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0321U, 0323U, 0329U, 0330U, U0331U, 0353U, 0354U, A4596
10/20/2022 Commercial, Medicare, and Medicaid Codes added effective 1/1/2023: ▪ Removed deleted CPT codes: 0012U, 0013U, and 0013U ▪ Added CPT codes: A4596, 0353U, and 0354U 10/17/2022 ▪ Added CPT code tables for Commercial, Medicare, and Medicaid LOBs.