CurrentAetnaPolicy 0438

Obsolete and Unreliable Tests and Procedures

Defines tests and procedures Aetna considers obsolete or unreliable (experimental/investigational) because they have been superseded by better methods or are not recommended by specialty societies; applies to Aetna medical policy determinations and providers submitting claims.

Policy Summary

PayerAetna

PolicyObsolete and Unreliable Tests and Procedures

Policy CodePolicy 0438

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit claims for listed CPT/HCPCS codes for the specified indications; these tests/procedures are considered experimental/investigational and not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

34CMS-designated obsolete diagnostic tests listed

20Other obsolete procedures listed

multipleCPT/HCPCS/ICD-10 codes mapped to noncoverage

23+References cited

Next reviewScheduled review

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Experimental and Investigational / Obsolete lists

Aetna considers the following tests and procedures experimental and investigational because CMS or other authorities have designated them obsolete or they have been replaced by more advanced procedures:

CMS-designated obsolete tests: List of 34 diagnostic tests (items 1-34) considered experimental/investigational

See source for full enumerated list

Obsolete or Unreliable Tests/Procedures Identified

Items discussed as obsolete or unreliable with supporting study findings

Radical parametrectomy after simple hysterectomy: In a retrospective series of 30 patients with low-risk early-stage cervical cancer, no residual tumor or nodal metastasis were found and only 1 recurrence after median 99-month follow-up; authors concluded radical parametrectomy may be avoided for low-risk patients.tumor <2 cm and invasion <10 mm; histology squamous/adenocarcinoma/adeno-squamous

Pareja et al. 2018

Chest radiography for rib fractures: Systematic review of 13 studies suggested lung ultrasound may be superior to chest radiograph for detecting rib fractures, but studies were small, single-center and at risk of bias; no definitive statement could be made.post-blunt chest wall trauma

Battle et al. 2019

Visceral osteopathy diagnostic techniques: Systematic review found diagnostic techniques used in visceral osteopathy to be unreliable and efficacy evidence absent or biased.inter-/intra-rater reliability or RCTs

Guillaud et al. 2018

Solitary CTA for vascular graft infection (VGI): Meta-analysis demonstrated CTA pooled sensitivity 0.67 and specificity 0.63, inferior to FDG-PET(/CT) and WBC scintigraphy ± SPECT/CT; authors concluded solitary CTA appears obsolete for diagnosing VGI.evaluation for suspected VGI

Reinders Folmer et al. 2018

Ali Krogius procedure for patellofemoral instability: Retrospective series (33 knees) reported re-dislocation rates ~24% (higher in ≤16 yr patients); authors recommend the AK procedure be regarded as obsolete due to relatively high re-dislocation rates.recurrent patellar dislocation

Bangert et al. 2022

Hysterosalpingography (HSG) vs HyFoSy: Recent literature notes hysterosalpingo-foam sonography (HyFoSy) as a favorable alternative for tubal patency assessment though HSG remains commonly used; HyFoSy has advantages endorsed in comparative studies.infertility evaluation/tubal patency testing

Ramos et al. 2022; Lee & Kilcoyne 2023

The CPT, HCPCS and ICD-10 codes listed in the coding sections of this Clinical Policy Bulletin are identified as not covered for the specific indications described in this policy. Claims submitted using these codes for the enumerated obsolete or experimental indications are subject to denial as noncovered services.

This Clinical Policy Bulletin is provided to assist in administering plan benefits and to inform clinical and claims decisions. It does not constitute a contract, guarantee of coverage, or medical advice, and plan determinations remain subject to the terms of the member’s benefit plan.

The tests and procedures enumerated in this bulletin are considered experimental and investigational / not medically necessary for the listed indications because they are obsolete, unreliable, or have been replaced by superior diagnostic or therapeutic alternatives as described in the policy.

None listed — tests enumerated in the policy are deemed obsolete/unreliable

None listed — the tests enumerated in this policy (examples below) are deemed obsolete/unreliable and considered experimental/investigational because they have been superseded by more accurate, reliable or less labor-intensive methods.

Examples of laboratory tests deemed obsolete/unreliable: Lupus erythematosus (LE) cell test; counterimmunoelectrophoresis; mechanical fragility (RBC) test; serum mucoprotein (seromucoid) assay; amylase blood isoenzymes (electrophoretic); chromium blood; serum glutamate dehydrogenase; thymol turbidity; Congo red (blood); cephalin flocculation; zinc sulphate turbidity; and related assays.

Replaced by modern immunoassays such as ELISA and other quantitative tests; see background discussion

Evaluation of suspected vascular graft infection — imaging recommendations

Evaluation of suspected vascular graft infection — when available, FDG‑PET/CT or white blood cell (WBC) scintigraphy with SPECT/CT are preferred over solitary CTA due to superior diagnostic performance.

Preferred imaging for suspected VGI: Use FDG‑PET(/CT) or WBC scintigraphy ± SPECT/CT rather than solitary CTA when clinically appropriate and available.

Meta-analysis: pooled sensitivities — CTA 0.67, FDG‑PET 0.94, FDG‑PET/CT 0.95, WBC scintigraphy 0.90, WBC+SPECT/CT 0.99; pooled specificities: CTA 0.63, FDG‑PET/CT 0.80, WBC SPECT/CT 0.82. WBC SPECT/CT showed highest diagnostic performance but is time-consuming and less available; FDG‑PET/CT may be favorable as initial imaging (Reinders Folmer et al. 2018).

Risk of relying on solitary CTA: Solitary CTA has lower sensitivity and specificity compared with FDG‑PET/CT and WBC SPECT/CT and therefore may be considered an obsolete diagnostic approach for VGI.evaluation for suspected VGI

See meta-analysis results

Coding — Affected CPT/HCPCS/ICD-10 Codes

CPT codes listed as not covered for CPB indicationsCPTNot Covered

30210	Displacement therapy (Proetz type)
51020	Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material
51030	with cryosurgical destruction of intravesical lesion
51605	Injection procedure and placement of chain for contrast and/or chain urethrocystography
52250	Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration
55705	Biopsy, prostate; incisional, any approach
55720	Prostatotomy, external drainage of prostatic abscess, any approach; simple
55725	Prostatotomy, external drainage of prostatic abscess; complicated
82024	Adrenocorticotropic hormone (ACTH) [animal tests]
82150	Amylase [electrophoretic]

1–10 of 13

1/2

HCPCS codes listed as not covered for CPB indicationsHCPCSNot Covered

P2028	Cephalin floculation, blood
P2029	Congo red, blood
P2033	Thymol turbidity, blood
P2038	Mucoprotein, blood (seromucoid) (medical necessity procedure)
S9025	Omnicardiogram/cardiointegram

Colectomy CPT codes (not covered for epilepsy indication)CPTNot Covered

44139	Mobilization (take-down) of splenic flexure
44213	Mobilization (take-down) of splenic flexure (laparoscopic?)
44140-44147	Colectomy, partial
44204, 44206-44208	Colectomy, partial (laparoscopic codes)
44150-44151, 44155-44158, 44210-44212	Colectomy, total
44160, 44205	Colectomy, partial, with removal of terminal ileum with ileocolostomy

ICD-10 / HCPCS codes referenced for exclusionmixedNot Covered

G40.001-G40.919	Epilepsy and recurrent seizures
J9165	Injection, diethylstilbestrol diphosphate, 250 mg
M0100	Intragastric hypothermia using gastric freezing
I25.10-I25.9	Chronic ischemic heart disease
I48.0, I48.2, I48.91	Atrial fibrillation diagnoses
L70.0-L70.9	Acne

Additional CPT codes not covered for listed indicationsCPTNot Covered

37616	Ligation, major artery; chest [mammary artery]
67570	Optic nerve decompression (eg, incision or fenestration of optic nerve sheath)

Not applicable — placeholder

Not applicableNo applicable threshold or value specified for this item; the policy marks this field as 'Not applicable'.

Source guidanceCPT/HCPCS threshold groups are described elsewhere in the policy; this entry is a placeholder indicating no threshold applies.

Administrative noteRefer to the CPT/HCPCS code sections for specific noncoverage listings rather than threshold values.

Provider Actions — Prior Authorization, Documentation, and Clinical Guidance

Prior Authorization

Prior authorization / coverage stance

Prior authorization requirements: No specific prior authorization codes or formal prior authorization requirements are listed in this policy for the procedures and tests identified as obsolete. Providers should be aware that claims for the listed CPT/HCPCS/ICD-10 codes when used for the indicated obsolete or non‑recommended indications (for example, colectomy to treat epilepsy, solitary CTA to diagnose vascular graft infection, or other procedures named as obsolete) may be subject to denial as not covered or inappropriate use. Confirm local plan prior‑authorization rules at the time of service.

No specific prior authorization codes provided in policy text.
Claims for listed CPT/HCPCS/ICD‑10 codes for indicated obsolete uses may be denied.

Documentation Required

Preferred imaging sequence for vascular graft infection (VGI)

Preferred imaging sequence for suspected vascular graft infection (VGI): evidence supports FDG‑PET/CT or WBC scintigraphy with SPECT/CT over solitary CTA. Systematic review data show pooled sensitivities of ~0.95 for FDG‑PET/CT and ~0.99 for WBC SPECT/CT versus ~0.67 for CTA; pooled specificities also favored PET/CT and WBC SPECT/CT. When available, FDG‑PET/CT is an appropriate initial advanced imaging choice; WBC SPECT/CT has the highest diagnostic performance but may be time‑consuming and less available.

Solitary CTA sensitivity ~0.67, specificity ~0.63.
FDG‑PET/CT sensitivity ~0.95, specificity ~0.80.
WBC scintigraphy + SPECT/CT sensitivity ~0.99, positive post‑test probability ~96%.

Denial Risk

Noncoverage triggers (examples)

Noncoverage triggers / denial risk examples: The policy lists specific CPT and HCPCS codes considered obsolete or not covered for the indicated diagnoses or uses (e.g., colectomy codes when billed for epilepsy, obsolete laboratory and diagnostic procedure codes listed in the policy). Claims using those codes for the non‑endorsed indications may be denied as not covered or experimental.

Colectomy CPT codes (e.g., 44139, 44140‑44147, 44150‑44158, 44160, 44204‑44213) listed as not covered for treating epilepsy (ICD‑10 codes G40.001‑G40.919).
Multiple listed CPT/HCPCS laboratory and procedural codes identified as obsolete in the policy.

Note

Supporting clinical justification

Supporting clinical justification: This policy includes procedures deemed obsolete by authorities such as CMS and other reviewers. Examples include replacement of incisional prostate biopsy by transrectal ultrasound‑guided core needle biopsy, replacement of prostatotomy by transurethral or transperineal drainage for prostate abscess, and replacement of contrast/chain urethrocystography by ultrasonography due to radiation exposure and invasiveness.

Core needle biopsy has supplanted incisional prostate biopsy for prostate cancer diagnosis.
Transurethral evacuation or transperineal aspiration have replaced prostatotomy for abscess drainage.
Ultrasonography has replaced contrast chain urethrocystography for urethrovesical imaging.

Note

Policy history / administrative notes

Administrative documentation: Policy review history and effective/next review dates are provided in the policy metadata. Providers should refer to the policy history and definitions links for details and check for updates or local plan-specific requirements.

Effective: 08/08/2000 (as listed).
Last review: 06/19/2023; Next review: 05/09/2024.

Definitions — Key Terms

Obsolete tests and procedures — definition

DefinitionObsolete tests and procedures are those that are outdated, no longer standard of care, have been replaced by more advanced procedures, or are not recommended by professional societies.

ExamplesIncludes tests replaced by newer techniques (e.g., LE cell test replaced by immunoassays) and procedures supplanted by less invasive methods (e.g., incisional prostate biopsy replaced by transrectal ultrasound-guided core needle biopsy).

Implication for coverageItems designated obsolete are considered experimental/investigational and not medically necessary for the listed indications in this policy.

DocumentationRationale and background supporting obsolescence determinations should be referenced in the medical record when applicable.

Obsolete/Unreliable — definition and evidence basis

DefinitionAn obsolete or unreliable test/procedure is a diagnostic test or therapeutic procedure for which evidence indicates inferior diagnostic accuracy, poor reliability, higher complication or failure rates, or that a superior alternative is available.

Evidence basisDeterminations are supported by systematic reviews, meta-analyses, and comparative studies (examples: meta-analysis showing solitary CTA has lower sensitivity/specificity for vascular graft infection; systematic review showing visceral osteopathy diagnostic techniques are unreliable).

Clinical consequenceUse of obsolete/unreliable methods may lead to inferior diagnostic performance and risk of denial if used in place of recommended alternatives (e.g., prefer FDG-PET/CT or WBC SPECT/CT over solitary CTA for suspected vascular graft infection).

RecommendationProviders should use validated, evidence-supported alternatives and document clinical justification when older methods are employed.

Covered Indications / Rationale

Obsolete/unreliable tests and procedures — background

Tests enumerated in the policy are deemed obsolete/unreliable and are considered experimental/investigational; many have been replaced by newer assays or techniques.

Obsolete laboratory tests (policy examples): LE cell test; counterimmunoelectrophoresis; amylase electrophoretic isoenzymes; chromium (blood); serum glutamate dehydrogenase; mechanical fragility (RBC); thymol turbidity; mucoprotein (seromucoid); cephalin flocculation; Congo red (blood); zinc sulphate turbidity.

Replaced by modern immunologic and quantitative assays (e.g., ELISA); see background

Obsolete procedures (policy examples): Colectomy to treat epilepsy; Proetz displacement therapy; gastric bubble; gastric freezing; incisional prostate biopsy; mammary artery ligation; optic nerve decompression for NAION; paraffin oil injection; renal decapsulation; others listed in policy.

These procedures are considered obsolete based on historical evidence and specialty guidance

Evaluation of suspected vascular graft infection — diagnostic preference

For suspected vascular graft infection, prefer functional imaging (FDG‑PET/CT or WBC SPECT/CT) over solitary CTA when available; diagnostic performance data favor WBC SPECT/CT and FDG‑PET/CT.

Recommendation for VGI imaging sequence: Consider FDG‑PET(/CT) or WBC scintigraphy with SPECT/CT as the preferred initial diagnostic imaging modalities over solitary CTA when available.

Meta-analysis: WBC SPECT/CT had highest pooled sensitivity/specificity but is time-consuming and less available; FDG‑PET/CT may be favorable as initial imaging (Reinders Folmer et al. 2018).

Operational considerations: When WBC SPECT/CT is not available or practical, FDG‑PET/CT is an acceptable alternative; reliance on CTA alone may give inferior diagnostic accuracy.

Availability and time requirements may limit WBC SPECT/CT despite high diagnostic accuracy

OpenPayer

Obsolete and Unreliable Tests and Procedures

Coverage Criteria — Obsolete and Unreliable Tests/Procedures

Coding — Affected CPT/HCPCS/ICD-10 Codes

Provider Actions — Prior Authorization, Documentation, and Clinical Guidance

Background and Scope

Definitions — Key Terms

Covered Indications / Rationale

Ordering Requirements

Frequency Limits

Not Covered — Specific Tests and Procedures