HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Z-67-094
Topic:
Experimental/Investigational Services
Section:
Miscellaneous
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
March 2022
 
 

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 Position

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.

Nervous System

Procedure Code

Description

0533T

Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for six (6) days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report

0534T

Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for six (6) days up to 10 days; set-up, patient training, configuration of monitor

0535T

Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for six (6) days up to 10 days; data upload, analysis and initial report configuration

0536T

Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for six (6) days up to 10 days; download review, interpretation and report

0766T

Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve

0767T

Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed;  each additional nerve (List separately in addition to code for primary
procedure)

0768T

Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, subsequent treatment, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve

0769T

Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, subsequent treatment, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve (List separately in addition to code for primary
procedure)

0776T

 

Therapeutic induction of intra-brain hypothermia, including placement of a mechanical temperature-controlled cooling device to the neck over carotids and head, including monitoring (eg, vital signs and sport concussion assessment tool 5 [SCAT5]), 30 minutes of treatment


Eye

Procedure Code

Description

0100T

Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy

0308T

Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis

0329T

Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report

0333T

Visual evoked potential, screening of visual acuity, automated, with report

0378T

Visual field assessment, with concurrent real time data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional

0379T

Visual field assessment, with concurrent real time data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional

0469T

Retinal polarization scan, ocular screening with on-site automated results, bilateral

0472T

Device evaluation, interrogation, and initial programming of intraocular retinal electrode array (i.e., retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional

0473T

Device evaluation and interrogation of intraocular retinal electrode array (i.e., retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional

0506T

Macular pigment optical density measurement by heterochromatic flicker photometry, unilateral or bilateral, with interpretation and report

0604T

Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; initial device provision, set-up and patient education on use of equipment

0605T

Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days

0606T

Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days

0615T

Eye-movement analysis without spatial calibration, with interpretation and report

0616T

Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens

0617T

Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens

0618T

Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange

0687T

Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session

0688T

Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month

0704T

Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment

0705T

Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days

0706T

Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month

0730T

Trabeculotomy by laser, including optical coherence tomography (OCT) guidance

0810T

Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies

92145

Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report

95919

Quantitative pupillometry with physician or other qualified health care professional interpretation and report, unilateral or bilateral

C1839

Iris prosthesis

L8608

Miscellaneous external component, supply or accessory for use with the Argus II retinal prosthesis system


Face, Head and Neck

Procedure Code

Description

0639T

Wireless skin sensor thermal anisotropy measurement(s) and assessment of flow in cerebrospinal fluid shunt, including ultrasound guidance, when performed

0673T

Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance


Ear, Nose and Throat 

Procedure Code

Description

0485T

Optical coherence tomography (OCT) of middle ear, with interpretation and report; unilateral

0486T

Optical coherence tomography (OCT) of middle ear, with interpretation and report; bilateral

0583T

Tympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia

0725T

Vestibular device implantation, unilateral

0726T

Removal of implanted vestibular device, unilateral

0727T

Removal and replacement of implanted vestibular device, unilateral

0728T

Diagnostic analysis of vestibular implant, unilateral; with initial programming

0729T

Diagnostic analysis of vestibular implant, unilateral; with subsequent programming

0783T

Transcutaneous auricular neurostimulation, set-up, calibration, and patient education on use of equipment

30468

Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)

30469

Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling

C9771

Nasal/sinus endoscopy, cryoablation nasal tissue(s) and/or nerve(s), unilateral or bilateral


Respiratory System

Procedure Code

Description

0174T

Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation

0175T

Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation

0632T

Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance

0781T

Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; bilateral mainstem bronchi

0782T

Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; unilateral mainstem bronchus


Gastrointestinal System

Procedure Code

Description

0652T

Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

0653T

Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple

0654T

Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter

0736T

Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter

0748T

 

Injections of stem cell product into perianal peri-fistular soft tissue, including fistula preparation (e.g., removal of setons, fistula curettage, closure of internal openings) 

0771T

 

 

Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

0772T

 

 

Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; each additional 15 minutes intraservice time (List separately in
addition to code for primary service)

0773T

 

Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older

0774T

 

 

Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in
addition to code for primary service)

0779T

 

Gastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report

91022

Duodenal motility (manometric) study

A4563

Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each

A9268

Programmer for transient, orally ingested capsule

A9269

 

Programable, transient, orally ingested capsule, for use with external programmer, per month

C1748

Endoscope, single-use (i.e. disposable), upper GI, imaging/illumination device (insertable)

C9779

Endoscopic submucosal dissection (ESD), including endoscopy or colonoscopy, mucosal closure, when performed


Skin and Subcutaneous Tissue

Procedure Code

Description

0479T

Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children

0480T

Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (list separately in addition to code for primary procedure)

0552T

Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional

0640T

Noncontact near-infrared spectroscopy studies of flap or wound (i.e., for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition, interpretation and report, each flap or wound

0641T

Noncontact near-infrared spectroscopy studies of flap or wound (i.e., for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition only, each flap or wound

0642T

Noncontact near-infrared spectroscopy studies of flap or wound (i.e., for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); interpretation and report only, each flap or wound

0658T

Electrical impedance spectroscopy of one (1) or more skin lesions for automated melanoma risk score

0700T

Molecular fluorescent imaging of suspicious nevus; first lesion

0701T

Molecular fluorescent imaging of suspicious nevus; each additional lesion (list separately in addition to code for primary procedure)

96931

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion

96932

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion

96933

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion

96934

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (list separately in addition to code for primary procedure)

96935

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (list separately in addition to code for primary procedure)

96936

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (list separately in addition to code for primary procedure)

C1832

Autograft suspension, including cell processing and application, and all system components

C9250

Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 ml


Cardiovascular System

Procedure Code

Description

 

0266T

Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming and repositioning, when performed)

 

0267T

Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)

 

0268T

Implantation or replacement of carotid baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)

 

0269T

Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning when performed)

 

0270T

Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)

 

0271T

Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)

 

0272T

Interrogation device evaluation (in person), carotid sinus barorelfex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (i.e., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day);

 

0273T

Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (i.e., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming

 

0518T

Removal of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing

 

0521T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimulator for left ventricular pacing

 

0522T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, wireless cardiac stimulator for left ventricular pacing

 

0541T

Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study

 

0542T

Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study; interpretation and report

 

0543T

Transapical mitral valve repair, including transthoracic echocardiography, when performed, with placement of artificial chordae tendineae

 

0553T

Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention

 

0571T

Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed

 

0572T

Insertion of substernal implantable defibrillator electrode

 

0573T

Removal of substernal implantable defibrillator electrode

 

0574T

Repositioning of previously implanted substernal implantable defibrillator-pacing electrode

 

0575T

Programming device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional

 

0576T

Interrogation device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter

 

0577T

Electrophysiologic evaluation of implantable cardioverter-defibrillator system with substernal electrode (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)

 

0578T

Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional

 

0579T

Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

 

0580T

Removal of substernal implantable defibrillator pulse generator only

 

0644T

Transcatheter removal or debulking of intracardiac mass (i.e., vegetations, thrombus) via suction (i.e., vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated blood, including imaging guidance, when performed

 

0645T

Transcatheter implantation of coronary sinus reduction device including vascular access and closure, right heart catheterization, venous angiography, coronary sinus angiography, imaging guidance, and supervision and interpretation, when performed

 

0659T

Transcatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (i.e., fluoroscopy), angiography, and radiologic supervision and interpretation

 

0674T

Laparoscopic insertion of new or replacement of permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including an implantable pulse generator and diaphragmatic lead(s)

 

0675T

Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first lead

 

0676T

Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional lead (list separately in addition to code for primary procedure)

 

0677T

Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first repositioned lead

 

0678T

Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional repositioned lead (list separately in addition to code for primary procedure)

 

0679T

Laparoscopic removal of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function

 

0680T

Insertion or replacement of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing lead(s)

 

0681T

Relocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing dual leads

 

0682T

Removal of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function

 

0683T

Programming device evaluation (in-person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function

 

0684T

Peri-procedural device evaluation (in-person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review, and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function

 

0685T

Interrogation device evaluation (in-person) with analysis, review and report by a physician or other qualified health care professional, including connection, recording and disconnection per patient encounter, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function

 

0695T

Body surface-activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of implant or replacement

 

0696T

Body surface-activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of follow-up interrogation or programming device evaluation

 

0744T

Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft (e.g., polyester, ePTFE, bovine pericardium), when performed

 

0745T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance  

 

0746T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan

 

0747T

Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia

 

0764T

Assistive algorithmic electrocardiogram risk-based assessment for cardiac dysfunction (e.g., low-ejection fraction, pulmonary hypertension, hypertrophic cardiomyopathy); related to concurrently performed electrocardiogram (List separately in addition to code for primary procedure)

 

0765T

 

Assistive algorithmic electrocardiogram risk-based assessment for cardiac dysfunction (e.g., low-ejection fraction, pulmonary hypertension, hypertrophic cardiomyopathy); related to previously performed electrocardiogram

 

0793T

 

Percutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance

 

0805T

 

Transcatheter superior and inferior vena cava prosthetic valve implantation (i.e., caval valve implantation [CAVI]); percutaneous femoral vein approach

 

0806T

Transcatheter superior and inferior vena cava prosthetic valve implantation (i.e., caval valve implantation [CAVI]); open femoral vein approach

 

33267

Exclusion of left atrial appendage, open, any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip)

 

33268

Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip) (list separately in addition to code for primary procedure)

 

33269

Exclusion of left atrial appendage, thoracoscopic, any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip)

 

33440

Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure)

 

93895

Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

 

C1825

Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s)

 

C9758

Blinded procedure for NYHA class III/IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study

 

C9759

Transcatheter intraoperative blood vessel microinfusion(s) (i.e., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when performed

 

C9760

Non-randomized, non-blinded procedure for nyha class II, III, IV heart failure; transcatheter implantation of interatrial shunt, including right and left heart catheterization, transeptal puncture, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (i.e., ultrasound, fluoroscopy), performed in an approved investigational device exemption (IDE) study

 

C9764

Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed

 

C9765

Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed

 

C9766

Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed

 

C9767

Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed

 

C9772

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed

 

C9773

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed

 

C9774

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed

 

C9775

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed

 

C9780

Insertion of central venous catheter through central venous occlusion via inferior and superior approaches (i.e., inside-out technique), including imaging guidance

 

C9782

Blinded procedure for New York Heart Association (NYHA) class ii or iii heart failure, or Canadian cardiovascular society (ccs) class iii or iv chronic refractory angina; transcatheter intramyocardial transplantation of autologous bone marrow cells (e.g., mononuclear) or placebo control, autologous bone marrow harvesting and preparation for transplantation, left heart catheterization including ventriculography, all laboratory services, and all imaging with or without guidance (e.g., transthoracic echocardiography, ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study

 

C9783

Blinded procedure for transcatheter implantation of coronary sinus reduction device or placebo control, including vascular access and closure, right heart catheterization, venous and coronary sinus angiography, imaging guidance and supervision and interpretation when performed in an approved investigational device exemption (ide) study

 

K1030

External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only

 

Q0035

Cardiokymyography (CKG)

 

S3902

Ballistocardiogram

 

S9025

Omnicardiogram/cardiointegram

 

Musculoskeletal System 

Procedure Code

Description

0200T

Percutaneous sacral augmentation (Sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one (1) or more needles, includes imaging guidance and bone biopsy, when performed

0201T

Percutaneous sacral augmentation (Sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two (2) or more needles, includes imaging guidance and bone biopsy, when performed

0202T

Posterior vertebral joint(s) arthroplasty (i.e., facet joint(s) replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine

0219T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical

0220T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic

0221T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar

0222T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (list separately in addition to code for primary procedure)

0263T

Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest

0264T

Intramuscular autologous bone marrow cell therapy with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest

0265T

Intramuscular aulogous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy

0489T

Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells

0490T

Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands

0547T

Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score

0565T

Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation

0566T

Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral

0594T

Osteotomy, humerus, with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments, computations of adjustment schedules, and management of the intramedullary lengthening device

0691T

Automated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report

   

0717T

Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs

0718T

Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral

0719T

Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment

0778T

Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function

C1734

Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)

S2348

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple


Genitourinary System

Procedure Code

Description

0499T

Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed

0567T

Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound

0568T

Introduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound

0672T

Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence

53451

Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance

53452

Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance

53453

Periurethral transperineal adjustable balloon continence device; removal, each balloon

53454

Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume

57465

Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (list separately in addition to code for primary procedure)


Endocrine System

Procedure Code

Description

0338T

Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral

0339T

Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral

0602T

Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent

0603T

Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours

0686T

Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance

C9790

Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including image guidance


Injection

Procedure Code

Description

0708T

Intradermal cancer immunotherapy; preparation and initial injection

0709T

Intradermal cancer immunotherapy; each additional injection (list separately in addition to code for primary procedure)

0732T

Immunotherapy administration with electroporation, intramuscular

90689

Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 ml dosage, for intramuscular use



Miscellaneous

Procedure Code

Description

0342T

Therapeutic apheresis with selective HDL delipidation and plasma reinfusion

0358T

Bioelectrical impedance analysis whole body composition assessment, with interpretation and report

0422T

Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral

0437T

Implantation of non-biologic or synthetic implant (i.e., polypropylene) for fascial reinforcement of the abdominal wall (list separately in addition to primary procedure)

0465T

Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)

0488T

Preventive behavior change, online/electronic structured intensive program for prevention of diabetes using a standardized diabetes prevention program curriculum, provided to an individual, per 30 days

0546T

Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report

0559T

Anatomic model 3D-printed from image data set(s); first individually prepared and processed component of an anatomic structure

0560T

Anatomic model 3D-printed from image data set(s); each additional individually prepared and processed component of an anatomic structure (list separately in addition to code for primary procedure)

0561T

Anatomic guide 3D-printed and designed from image data set(s); first anatomic guide

0562T

Anatomic guide 3D-printed and designed from image data set(s); each additional anatomic guide (list separately in addition to code for primary procedure)

0689T

Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (i.e., organ, gland, tissue, target structure)

0690T

Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained with diagnostic ultrasound examination of the same anatomy (i.e., organ, gland, tissue, target structure) (list separately in addition to code for primary procedure)

0692T

Therapeutic ultrafiltration

0693T

Comprehensive full body computer-based markerless 3D kinematic and kinetic motion analysis and report

0694T

3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3-dimensional automatic specimen reorientation, interpretation and report, real-time intraoperative

0721T

Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained without concurrent CT examination of any structure contained in previously acquired diagnostic imaging

0723T

Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained without diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session

0731T

Augmentative AI-based facial phenotype analysis with report

0737T

Xenograft implantation into the articular surface

36836

Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation

36837

Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation

C9788

Opto-acoustic imaging, breast (including axilla when performed), unilateral, with image documentation, analysis and report, obtained with ultrasound examination

 

77089

77090

77091

77092

0198T

0444T

0445T

0470T

0471T

0484T

0497T

0498T

0505T

0523T

0525T

0526T

0527T

0528T

0529T

0530T

0531T

0532T

0544T

0545T

0569T

0570T

0596T

0597T

0598T

0599T

0600T

0601T

0607T

0608T

0613T

0615T

0620T

0621T

0622T

0646T

0660T

0661T

0662T

0663T

K1006

K1009

L2006

L8701

L8702




Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

An experimental/investigational service is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



Links






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.