CurrentEmblemHealthPolicy MG.MM.AD.11

Medical Necessity Guidelines: Experimental, Investigational or Unproven Services

Defines EmblemHealth's medical necessity determination and exclusion policy for services, procedures, devices, treatments and supplies considered experimental, investigational or unproven; includes evidentiary hierarchy and a (partial) list of CPT/HCPCS codes deemed investigational/noncovered for Commercial plans in this part.

Policy Summary

PayerEmblemHealth

PolicyMedical Necessity Guidelines: Experimental, Investigational or Unproven Services

Policy CodePolicy MG.MM.AD.11

Change TypeAdded/Removed codes (revision history includes many effective-dated code changes)

Effective Date

Next Review Date

Key ActionTreating physician or PCP must submit clinical evidence demonstrating the patient meets criteria for the treatment/procedure; without documentation EmblemHealth cannot properly review prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

Removed Codes effective 10/1/2026: Commercial and Medicare: 69433; Commercial only: 69705, 69706.

Added New Codes effective 4/01/2026: Commercial and Medicare: 0614U-0630U; Commercial only: A2040-A2045, Q4418-Q4440 (list).

Removed Code 27570 (4/9/2026).

Added Codes effective 7/15/2026: Commercial: 0813T (3/23/2026 entry).

Removed multiple Commercial and Commercial+Medicare codes effective 7/15/2026 per 2/27/2026 revision (list includes 43210, 43290, 43291, 0675T, etc.).

Added New Codes effective 1/01/2026 (1/5/2026 revision): multiple Commercial and Medicare codes including 43889, 62330, 81354, 81524, 87183, 93145, 0600U-0613U, 0988T-1024T, etc.

Removed Deleted Codes effective 1/01/2026: lists of Commercial and Medicare codes (e.g., 0033U, 0042T, 0266T-0275T, 0361U, 0394T, etc.).

Correction to 2/27/2026 Revision: Commercial codes 43290 and 43291 remain Experimental & Investigational.

Multiple prior additions and removals spanning 2023-2025 captured in revision history (e.g., additions effective 7/1/2025, 4/14/2025, etc.).

Coverage Summary & Scope

EmblemHealth limits coverage to services, devices, treatments and procedures for which safety and efficacy have been proven and are comparable or superior to conventional therapies. This guideline defines the terms investigational/experimental/unproven and specifies evidentiary standards used to assess services. Plan benefits and any applicable legal mandates govern coverage if there is a discrepancy between this guideline and a member's benefit program.

Key policy attributes

policy_numberMG.MM.AD.11

last_review2026-04-24

coverage_stanceLimits coverage to services proven safe and effective; many CPT/HCPCS codes designated experimental/investigational (Commercial & Medicare lists) — stance: mixed (restrictive for listed codes)

scope_summaryDefines medical necessity determination and exclusion policy for services, procedures, devices, treatments and supplies considered experimental, investigational or unproven; includes evidentiary hierarchy and partial lists of CPT/HCPCS codes (Commercial and Medicare) deemed investigational/noncovered.

LOBs_affectedCommercial & Medicare

has_material_changetrue — revision history shows multiple material additions/removals (effective-dated code changes in 2026, e.g., added 0614U-0630U and removed 69433/69705/69706).

Medical-Necessity Criteria & Definitions

Definition of Investigational/Experimental/Unproven

The Plan defines “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 being treated. A service is considered investigational, experimental or unproven if ANY of the following are met:

ANY of the following

The service, procedure or supply requiring Federal or other Governmental body approval (e.g., drugs, devices) does not have final or unrestricted market approval from the Food and Drug Administration (FDA) or final approval from any other governmental regulatory body for use in treatment of the specified condition. Interim regulatory approvals or conditional approvals do not substitute for final or unrestricted market approval.
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 indicating the proposed treatment is likely to be beneficial to the member.
Peer‑reviewed medical literature contains inconclusive evidence that the service, procedure or supply has a beneficial effect on health outcomes.

Commercial Plans — Experimental / Noncovered Codes (partial lists)

Commercial Plans - Investigational / Noncovered CPT/HCPCS codes (partial list in this part)CPT|HCPCSNot Covered

26340
34718
53451
64655
64727
43295
0901T
0913T
0937T
0949T

1–10 of 157

1/16

Experimental & Noncovered Investigational by CPT Code (Commercial Plans)CPTNot Covered

11951	maps to various codes as listed in policy (example mapping entries)
11952	maps to various codes as listed in policy
11954	maps to various codes as listed in policy
19105
20939
20983
22526
22527
22586
23700

1–10 of 55

1/6

Medicare Plans — Experimental / Noncovered Codes (enumerated)

Medicare Plans - Experimental & Noncovered Investigational codes (enumerated)CPT|HCPCS|mixedNot Covered

28890	listed as Experimental & Noncovered Investigational (mapping examples provided)
64702	listed experimental & noncovered; mapped to multiple codes such as 64704, 64708, 64712, 64714, 64722, 64726, 64727
75898	listed experimental & noncovered with mappings (e.g., 76498, 77605, 77615, etc.)
81252	listed experimental & noncovered with mappings to 81253, 81254, 81283, 81289, 81291, 81328, 81332, 81346, 81354, 81383
81430	listed experimental & noncovered with many mapped targets (81431, 81434, 81470, 81471, 81490, 81493, 81503, 81524, 81529, 81535, 81536)
81558	listed experimental & noncovered with mappings (82726, 83006, 83722, 83789, 83951, 84112, 84378, 86039, 86200, 86225, 86235)
86382	listed experimental & noncovered with mappings (87183, 87801, 88120, 88121, 88187, 88323, 88346, 88350, 88368, 89240, 90867)
90868	mapped to 90869, 91113, 92145, 92449, 93740, 93895, 96904, 97026, 97039, 97139, 99070
0001U	Category III/temporary codes listed; extensive sequences: 0001U=0002U=0003U=0007M etc.
0016U	listed with multiple mappings (0017U, 0019U, 0020M, 0021U, 0024U, 0025U, 0029U, 0030U, 0031U, 0032U, 0034U)

Experimental & Noncovered / Investigational by CPT Code (Medicare Plans)CPTNot Covered

0165T
0465U
0453U
0165U
0466U
0166U
0467U
0158U
0469T
0159U

1–10 of 23

1/3

Experimental & Noncovered / Investigational (Medicare Plans) code mappings shown in partCPT|HCPCS|mixedNot Covered

.0809T = 0980T	mapping shown (Medicare Plans)
.0810T = 0981T	mapping shown (Medicare Plans)
.0814T = 0982T	mapping shown (Medicare Plans)
.0815T = 0983T	mapping shown (Medicare Plans)
.0816T = 0984T	mapping shown (Medicare Plans)
.0817T = 0985T	mapping shown (Medicare Plans)
.0818T = 0986T	mapping shown (Medicare Plans)
.0805T = A2002	mapping shown (Medicare Plans)
.0806T = A2004	mapping shown (Medicare Plans)
.0807T = A2005	mapping shown (Medicare Plans)

1–10 of 20

1/2

Codes Added / Removed — Revision Highlights

Commercial and/or Medicare - Added/Removed/Corrected codes in revision historyCPT|HCPCS|mixed

69433	Removed effective 10/1/2026 (Commercial and Medicare)
69705	Removed effective 10/1/2026 (Commercial only)
69706	Removed effective 10/1/2026 (Commercial only)
0614U	Added effective 4/01/2026 (Commercial and Medicare)
0615U	Added effective 4/01/2026 (Commercial and Medicare)
0616U	Added effective 4/01/2026 (Commercial and Medicare)
0617U	Added effective 4/01/2026 (Commercial and Medicare)
0618U	Added effective 4/01/2026 (Commercial and Medicare)
0619U	Added effective 4/01/2026 (Commercial and Medicare)
0620U	Added effective 4/01/2026 (Commercial and Medicare)

Examples of Removed Codes (various dates/effectiveness)CPT|HCPCS|mixedNot Covered

27570	Removed 4/9/2026 (Commercial and Medicare)
43210	Removed 2/27/2026 (Commercial)
43290	Removed 2/27/2026 (Commercial) - correction notes indicate remains E&I
43291	Removed 2/27/2026 (Commercial) - correction notes indicate remains E&I
0675T	Removed 2/27/2026 (Commercial)
0338T	Removed 2/27/2026 (Commercial and Medicare)
0033U	Removed 1/01/2026 (Commercial and Medicare)
0042T	Removed 1/01/2026 (Commercial)
0266T	Removed 1/01/2026 (Commercial and Medicare)
0361U	Removed 1/01/2026 (Commercial)

Provider Actions & Billing Rules

Documentation Required

Clinical evidence required for PA review

Treating physician or PCP must submit clinical evidence demonstrating the patient meets criteria for the treatment/procedure; without documentation EmblemHealth cannot properly review prior authorization requests.

Billing Rule

Do not bill covered/reimbursed — experimental/investigational

For Commercial Plans, the listed CPT/HCPCS codes are designated Experimental & Noncovered/Investigational and should be treated as noncovered for adjudication and billing.

Applies to Commercial Plans.
Referenced code groups: Commercial Plans - Investigational / Noncovered CPT/HCPCS codes (partial list) (see Commercial tables and mappings in the policy).

Background & Rationale

EmblemHealth restricts coverage to interventions with demonstrated safety and effectiveness; services are considered investigational, experimental or unproven when they lack unrestricted regulatory approval, have insufficient or inconclusive medical/scientific evidence (adequate evidence requires at least two supporting documents), show inconclusive peer-reviewed benefit, are less beneficial than established alternatives, or otherwise lack established safety and efficacy. EmblemHealth requires providers to submit clinical evidence for prior authorization review and reserves the right to revise conclusions as clinical information changes. When this guideline conflicts with a member's benefits program or legal mandates (state, Federal, or CMS), the benefits program or mandate governs.

A service is considered investigational, experimental or unproven if ANY of the listed criteria are met (e.g., lack of final/unrestricted governmental approval; insufficient or inconclusive evidence; inconclusive peer-reviewed literature; inferior to established alternatives; lack of established safety/efficacy).

Revision History (chronological highlights)

2026-04-24 (effective 10/1/2026)removed

Removed Codes effective 10/1/2026: Commercial and Medicare: 69433; Commercial only: 69705, 69706. (material)

2026-04-24 (effective 4/01/2026)added

Added New Codes effective 4/01/2026: Commercial and Medicare: 0614U-0630U; Commercial only: A2040-A2045, Q4418-Q4440. (material)

2026-04-09removed

Removed Code: 27570 (Commercial and Medicare). (material)

Policy Summary

PayerEmblemHealth

PolicyMedical Necessity Guidelines: Experimental, Investigational or Unproven Services

Policy CodePolicy MG.MM.AD.11

Change TypeAdded/Removed codes (revision history includes many effective-dated code changes)

Effective Date

Next Review Date

SourceLink

On This Page

Investigational / Noncovered Procedure Codes (Commercial Plans): The following CPT/HCPCS procedure codes are considered investigational and unproven for Commercial Plans and therefore are not covered by the Plan: 26340, 34718, 53451, 64655, 64727 and associated code mappings listed in the policy tables. (See the policy’s Commercial CPT/HCPCS code table for the complete, authoritative listing.)

Operational: Providers should reference the Commercial CPT/HCPCS code table in this guideline for the full list of specific code-to-code mappings and noncovered codes when submitting claims or requesting prior authorization.

Investigational / Noncovered Procedure Codes (Medicare Plans): For Medicare Plans, a separate Medicare CPT/HCPCS code table identifies procedure codes considered investigational/unproven and not covered under Medicare benefits. Providers must consult the Medicare code table in this guideline and applicable Medicare policy directives for coverage determination and billing guidance.

Operational: EmblemHealth adheres to Federal and state program directives; for Medicare members, Medicare-specific coverage rules and the Medicare code table govern.

Hierarchy of Reliable Evidence

To determine whether a device, medical treatment or procedure is proven safe and effective, the Plan uses the following hierarchy of reliable evidence (listed highest to lowest):

Published formal technology assessments and/or high‑quality meta‑analyses.
Well‑designed randomized studies published in credible, peer‑reviewed literature.
High‑quality case‑control or cohort studies.
Historical control studies.
Reports of expert opinion from national professional medical societies or national medical policy organizations.

Investigational / Experimental / Unproven: 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.

Adequate Evidence: At least two documents of medical and scientific evidence that indicate the proposed treatment is likely to be beneficial to the member.

Reliable Evidence: Scientifically valid data published in peer‑reviewed medical and scientific literature; excludes abstracts, anecdotal reports, or provider opinions without supporting publishable data.

Final or Unrestricted Market Approval: Full approval from the FDA or another governmental regulatory body for the specified indication; interim or conditional approvals do not meet this standard.

Medically Necessary: Services, devices or procedures for which safety and efficacy have been proven and which are comparable or superior to conventional therapies for the member’s condition.

Denial Risk

Do not bill covered codes designated investigational

Claims submitted for the listed CPT/HCPCS codes for the specified plan types should be treated as non-covered/investigational per policy and are subject to denial; providers must not expect payment for these codes when billed under the listed plan types.

There is claim denial risk for codes designated Experimental & Noncovered/Investigational.
Providers must not expect payment for the listed codes under the specified plan types (see Commercial and Medicare lists).

Billing Rule

Do not cover Experimental & Investigational CPT T/U codes for Medicare Plans

Claims for the listed CPT T and U temporary/miscellaneous codes should be adjudicated as experimental and noncovered/investigational for Medicare Plans per this code list segment.

Reference Medicare code tables and mappings in the policy (Medicare Plans - Experimental & Noncovered Investigational by CPT/HCPCS Code).
Temporary/category III T and U code ranges and many specific T/U codes are explicitly listed as not covered in the Medicare tables.

Billing Rule

Code reporting and mapping

Providers must bill using the current CPT/HCPCS code appropriate for the service; the policy lists codes designated Experimental & Noncovered / Investigational and codes added or removed with specified effective dates — claims will be processed according to the listed status and effective dates.

Bill using current CPT/HCPCS codes reflected in the policy.
Be aware of code-to-code mappings shown in the Commercial and Medicare tables when selecting reporting codes.

Documentation Required

Use revision history for effective dates

Providers should reference the revision history effective dates when submitting claims for codes added or removed to ensure correct billing and eligibility per Commercial vs Medicare scope.

Check revision history entries for effective dates (examples shown for 4/01/2026, 1/01/2026, 7/15/2026, etc.).
Apply Commercial vs Medicare scope as noted in each revision history entry.

Billing Rule

Effective-dated code changes

Some code additions are effective on specified future dates (e.g., codes added with future effective dates listed in the revision history); providers must apply codes only on or after their effective dates when submitting claims.

Examples: codes added effective 4/01/2026 and 7/15/2026 are noted in the revision history; follow those effective dates on claims.
Verify effective dates in the revision history for Commercial vs Medicare applicability.