Prior authorization for investigational codes

Prior authorization for the temporary CPT/HCPCS and other procedure codes listed as “Always Investigational” is not expected to result in coverage; these codes remain designated Always Investigational and are not payable unless the policy is changed.

• Examples include temporary codes 0596T, 0594T, 0598T, 0603T, 0600T, 0605T.

Investigational code billing guidance — denial risk

Billing services identified in the policy that are annotated 'Always Investigational' may lead to claim denial; providers should not expect routine payment when submitting these codes.

• Examples include diaphragmatic stimulation system codes (0676T, 0678T, 0679T) and autologous adipose-derived regenerative cell therapy entries (0718T).

Prior authorization expectation for listed investigational codes

Codes in the list that are designated 'Always Investigational' would require prior authorization if submitted, but the policy indicates these items are expected to be non‑covered even with authorization.

• Examples: 0764T, 0765T, and multiple Category III/temporary CPT codes marked Always Investigational.

Prior authorization not supported for listed investigational codes

Certain services listed (for example 92972 and 97037) are marked Always Investigational and prior authorization is not supported to obtain coverage for those services.

• 92972 — percutaneous transluminal coronary lithotripsy; 97037 — low‑level laser therapy.

Prior authorization for investigational devices will not make them covered

Device and supply HCPCS codes shown as Always Investigational will not be rendered covered by prior authorization; prior authorization does not convert investigational device entries into covered items.

• Examples include Q4339–Q4345 and device codes A4543/A4544, E0721.

Prior authorization not applicable for Always Investigational codes

Codes that are explicitly labeled 'Always Investigational' are not eligible for prior authorization to obtain coverage; prior authorization does not change the investigational designation.

• Examples include endoscopy and advanced diagnostic codes such as 43290, 43291, 0813T, and multiple U/Q/E codes listed.

Remote therapeutic/physiologic monitoring codes are investigational

Remote therapeutic and remote physiologic monitoring codes listed in this policy are marked Always Investigational; prior authorization will not make these services covered.

• Examples: 98986 and 99445 are listed as Always Investigational in this section.

Prior authorization will not change investigational/cosmetic status

Prior authorization alone does not convert services designated Always Investigational or Always Cosmetic into payable services; authorization should not be used as a substitute for coverage criteria compliance.

• The policy explicitly states that items in these code groups are Always Investigational or Always Cosmetic and that prior authorization will not render them covered.

Investigational implantable aortic counterpulsation device codes — not covered by authorization

Implantable aortic counterpulsation ventricular assist system codes are designated Always Investigational; prior authorization is not described as enabling coverage for these devices.

• Examples: 0451T, 0452T, 0453T, 0456T are marked Always Investigational.

Prior authorization not indicated for investigational/cosmetic codes

Prior authorization is not indicated for codes the policy marks Always Investigational or Always Cosmetic because authorization will not make these services covered.

• The policy lists many device/programming, sensor, and novel procedure codes with ExceptionsNotes = Always Investigational.

Prior authorization not applicable for listed investigational/cosmetic codes

The policy reiterates that prior authorization does not render codes designated Always Investigational or Always Cosmetic payable; providers should not expect coverage after prior authorization.

• A long list of CPT/HCPCS codes in chunk 180 are designated Always Investigational/Always Cosmetic and prior authorization will not change coverage.

Prior authorization does not convert investigational status to payable

Prior authorization does not convert the investigational designation into coverage; listed codes remain not payable despite any authorization attempt.

• Examples: numerous Q‑codes (e.g., Q4168 and related Q4xxx entries) are explicitly noted as Always Investigational and not payable with authorization.

Provider action — see related items

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Provider action — see related items

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Provider action — see related items

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Provider action — see related items

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Digital mental health device services marked Always Investigational

Digital mental health treatment device supply and monthly treatment management codes are listed as Always Investigational and are not covered; do not expect payment or step‑therapy pathways for these codes.

• Example codes: G0552, G0553, G0554 are listed with ExceptionsNotes = Always Investigational.

Provider action — see related items

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Provider action — see related items

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Provider action — see related items

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Provider action — see related items

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Provider action — see related items

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Provider action — see related items

(No specific action required; placeholder entry preserved from inventory.)

Provider action — see related items

(No specific action required; placeholder entry preserved from inventory.)

Policy applies to Moda Health Commercial Group and Individual Members

This policy applies to Moda Health Commercial Group and Individual Members; providers should reference this policy when submitting claims for listed services as these are designated investigational or cosmetic and are not covered for the indicated member types.

Provider action — see related items

(No specific action required; placeholder entry preserved from inventory.)

Provider action — see related items

(No specific action required; placeholder entry preserved from inventory.)

Documentation expectation for amniotic membrane Q‑codes

When billing HCPCS Q‑codes for amniotic membrane/amnion products (for example Q4314–Q4326 and many Q4xxx entries), expect that these codes are designated Always Investigational; submit supporting documentation if desired but anticipate documentation requests or claim denial.

• Examples: Q4314, Q4315, Q4316 and the broader Q4xxx product listings are marked Always Investigational.

Documentation note — listed investigational services

When submitting services for codes listed as Always Investigational, include clear justification of medical necessity in documentation; however, the policy marks these services investigational which indicates coverage is not supported per policy.

• Examples: 43290, 43291, 0813T, and laboratory U‑codes (0531U, 0532U) are listed as Always Investigational.

Documentation expectation for investigational services

Providers should expect claims for codes listed in this section (for example 43290, 43291 and multiple U, Q, E and other codes) to be treated as investigational; maintain supporting documentation but coverage is not provided per this policy.

Documentation for sub‑scalp EEG services — detail service and programming

When reporting services for implanted sub‑scalp continuous bilateral EEG monitoring systems and related programming/analysis, submit detailed service descriptions and codes as listed; note these services are marked Always Investigational in this policy segment.

• Include programming, analysis, and duration details when billing the listed monitoring and programming entries.

Documentation — standard coding identification only

No additional documentation requirements beyond identifying the service by the listed code are specified in these chunks; follow standard claim documentation but recognize investigational designation remains.

Documentation implication — justify medical necessity though likely insufficient

Many codes include an ExceptionsNotes field marking them as Always Investigational; providers should still ensure medical‑necessity justification is documented though the policy marks them investigational and coverage is not supported.

Documentation note — Always Cosmetic codes are non‑covered

Codes explicitly labeled 'Always Cosmetic' (for example dermabrasion, chemical peels, blepharoplasty and related entries) are non‑covered cosmetic procedures; documentation supporting medical necessity is unlikely to change coverage.

• Examples: 15781–15783 (dermabrasion), 15788–15793 (chemical peels), 15820–15821 (blepharoplasty).

Use listed code/service descriptions when preparing documentation

Use the exact code and service descriptions provided in the policy when preparing documentation and claims for the listed items; the document pairs service descriptions with each code.

Documentation will not change coverage for Always Investigational services

Documentation submitted for services billed with codes labeled 'Always Investigational' will not be sufficient to obtain coverage because the policy designates these services as investigational and not covered.

Denial risk — investigational‑designated codes may be denied

Claims submitted with codes labeled Always Investigational are at risk for denial as not covered; submit claims with awareness that denial is likely for investigational‑designated codes.

• Examples cited in the policy: 0596T, 0603T, 0594T, 0598T and similar temporary codes.

Denial risk for investigational items

Services and items explicitly marked Always Investigational in the policy may be denied when billed to Moda Health Commercial Group and Individual Members; providers should not expect payment.

Denial risk for investigational/not covered codes

Claims submitted with codes listed as 'Always Investigational' or 'Not covered' are at elevated risk of denial for Moda Health Commercial Group and Individual Members; verify coverage stance before billing.

Denial risk — Always Investigational T‑codes

Claims for procedures listed with the note 'Always Investigational' (for example selected T‑codes such as 0897T–0900T) are subject to denial per the policy.

• Examples: 0897T, 0898T, 0899T, 0900T are listed with ExceptionsNotes = Always Investigational.

Claims for listed services/codes are at risk for denial

Claims for the listed services and codes in multiple sections of this document are designated Always Investigational and are at risk for denial when billed for covered members.

• Examples include device, implant, and biomarker codes (e.g., 0403U, 53451–53453, Q4334–Q4336).