Medical Necessity Guidelines: Experimental, Investigational or Unproven Services
Defines EmblemHealth's criteria for labeling devices, treatments, procedures, supplies or tests as investigational/experimental/unproven and the evidence hierarchy used to determine medical necessity; applies to EmblemHealth commercial benefit programs and providers requesting prior authorization.
Added New Codes effective 1/01/2026 for Commercial and Medicare where specified (e.g., 43889, 62330, 64567, many T/U codes, Q4398–Q4433).
Removed Deleted Codes effective 1/01/2026 (commercial and Medicare lists include numerous U/T codes and others).
Multiple CPT, HCPCS, and other procedure codes were added across Commercial and Medicare code lists (examples: 0814T–0864T series, many U and A codes, and device HCPCS like A4541–A4542).
Numerous CPT and other codes were removed from Commercial and Medicare lists (examples: 20560, 20561, 0324U, and many others).
Specific code additions effective 1/1/2023 and other future-effective dates (examples: 0357U–0385U, 0738T–0799T series).
Some prior coverage statuses were revised (e.g., codes previously listed as covered for Commercial or Medicare were changed in later entries).
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.