ModifiedPremera BluecrossPolicy N/A

Non-covered Experimental/Investigational Services

Lists services, procedures, devices, and codes the Plan considers experimental or investigational and therefore not covered; intended for providers and applies to Premera Bluecross members per the member's contract.

Policy Summary

PayerPremera Bluecross

PolicyNon-covered Experimental/Investigational Services

Policy CodePolicy N/A

Change TypeCoding updates — new CPT/HCPCS codes added

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements with the plan before billing services listed as investigational.

SourceLink

POLICY UPDATE CHANGES

Multiple new CPT and HCPCS procedure and device codes effective 07/01/2025 through 01/01/2026 were added to the coding section (examples include 0957T–0960T series, 0961T–0999T series, and numerous C-, E-, and other HCPCS codes).

~150+listed CPT/temporary codes in this part of the policy

~60+new or listed CPT/HCPCS codes in this excerpt

53+temporary/new or Category III codes listed

Nationalapplies to

Jun 1, 2026

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.

effective date shown

Experimental / Investigational — Coverage Criteria

Not Covered — Experimental/Investigational Services

Services listed below are considered investigational and therefore not covered

Primary rule: Services determined by the Plan to be experimental/investigational per the Plan's definition are not covered

The list is a general reference and not all-inclusive; separate policies may list other investigational services. If there is a difference between this table and the member's contract, the member's contract prevails; coverage depends on the contract effective date and service date.

Experimental/Investigational determination

Services are considered investigational when ANY of the following are true

Experimental/Investigational criteria: A drug or device cannot be lawfully marketed without FDA approval and has not been granted such approval on the date the service is provided

Experimental/Investigational criteria: The service is subject to oversight by an Institutional Review Board (IRB)

Experimental/Investigational criteria: No reliable evidence demonstrates the service is effective for clinical diagnosis, evaluation, management, or treatment

Reliable evidence includes peer-reviewed medical and scientific literature and assessments by the Blue Cross and Blue Shield Center for Clinical Effectiveness.

Experimental/Investigational criteria: The service is the subject of ongoing clinical trials to determine maximum tolerated dose, toxicity, safety, or efficacy

Experimental/Investigational criteria: Evaluation indicates additional research is necessary before the service can be classified as equally or more effective than conventional therapies

The list that follows is provided as a general reference and is not all-inclusive. Services that the Plan determines to be experimental or investigational but that are addressed in separate medical policies may not appear here. Codes and service statuses are reviewed and updated regularly; when there is a difference between this table and the member's contract, the member's contract prevails.

The coding sections in these chunks present CPT and temporary Category III code descriptions and short procedure summaries; they do not set forth specific medical necessity criteria, coverage determinations, or exclusions. Use the code descriptions for identification only—coverage decisions are determined by the Plan’s policy language and the applicable member contract.

Some listed HCPCS/C-codes explicitly reference investigational or approved investigational device exemption (IDE) contexts. For example, C9792 is described as a transcatheter left atrial-to-coronary sinus shunt procedure performed under general anesthesia in an approved IDE study, indicating the code is specific to investigational study use rather than routine clinical care.

This medical policy applies to Premera commercial plans and serves as a guide for coverage determinations; it does not apply to Medicare Advantage. Always verify applicability for a given member based on the member’s benefit contract.

The document excerpts reviewed do not include explicit statements labeled as 'not medically necessary.' Code listings and brief procedure descriptions are presented without separate "not medically necessary" declarations in these chunks.

Services that meet the Plan’s definition of experimental or investigational are considered investigational and therefore may be non‑covered or denied as not medically necessary. The policy defines investigational services as those that meet one or more criteria such as lack of required FDA approval, IRB oversight, insufficient reliable evidence of effectiveness, active clinical trials, or need for additional research.

Coding — Listed Codes and Updates

Not Covered CPT Codes (selected list)CPTNot Covered

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 (Notal Home OTC Program).
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 (Notal Home OTC Program).
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 (Notal Home OTC Program).
0607T	Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (e.g., ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment (mCor Heart Failure and Arrhythmia Management System).
0608T	Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (e.g., ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional (mCor Heart Failure and Arrhythmia Management System).
0609T	Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (NOCISCAN Suite).
0610T	Magnetic resonance spectroscopy, determination and localization of discogenic pain; transmission of biomarker data for software analysis (NOCISCAN Suite).
0611T	Magnetic resonance spectroscopy, determination and localization of discogenic pain; postprocessing for algorithmic analysis of biomarker data (NOCISCAN Suite).
0612T	Magnetic resonance spectroscopy, determination and localization of discogenic pain; interpretation and report (NOCISCAN Suite).
0613T	Percutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance (V-Wave Shunt).

1–10 of 64

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Provider Actions — Authorization, Documentation, and Billing

Denial Risk

Investigational Services — Coverage

Services identified as investigational in this policy are not covered by the Plan. Prior authorization does not make an investigational service covered.

Investigational services are not eligible for coverage regardless of prior authorization status.

Prior Authorization

Prior Authorization May Be Required for Major Device Procedures

Certain major device procedures (for example, procedures involving insertion or revision of intramedullary lengthening devices, integrated neurostimulators, or other new implantable systems) may require prior authorization. Verify PA requirements with the plan before scheduling these procedures.

Examples include codes for intramedullary lengthening device insertion and major implantable neurostimulator systems (see coding lists).
If PA is required and not obtained, the claim may be denied or the member may be billed for non-covered services.

Background and Scope

For the purposes of this policy, experimental/investigational is defined as treatments, procedures, devices, drugs, or supplies whose safety and/or effectiveness has not been established by available peer‑reviewed medical and scientific literature and regulatory status. The definition includes services that lack FDA approval, are under IRB oversight, are the subject of ongoing clinical trials, or otherwise require additional evidence before being considered established therapy.

Definitions

Experimental/Investigational — Definition

DefinitionTreatments, procedures, equipment, drugs, drug usage, medical devices, or supplies not established as safe and/or effective by review of established published medical and scientific literature.

ImplicationServices meeting this definition are considered investigational and are generally not covered by the Plan unless contract language specifies otherwise.

ReferenceConsult the applicable health benefit plan contract for the specific definition used by that contract.

Assistive/augmentative algorithmic analysis

ScopeAssistive or augmentative algorithmic analyses include algorithm- or AI-based analyses applied to clinical data such as ECGs, imaging, and pathology to support detection, quantification, ranking, or other augmentative outputs.

Examples

Revision History and Policy Changes

2026-06-01annual_reviewLatest

Annual review approved May 25, 2026; removed termed HCPCS codes C9794 and C9795.

2026-04-01coding_update

Added new HCPCS codes C1743 and G0680 and corrected CPT type from 94470 to 99470 effective April 1, 2026.

2026-01-01coding_update

Policy Summary

PayerPremera Bluecross

PolicyNon-covered Experimental/Investigational Services

Policy CodePolicy N/A

Change TypeCoding updates — new CPT/HCPCS codes added

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements with the plan before billing services listed as investigational.

SourceLink

On This Page

Prior Authorization

Verify Benefits and Prior Authorization

Verify member benefits and any prior authorization requirements with the member's contract or the Plan before providing services. This policy is a guide but the member contract and benefit booklet govern coverage.

Contact customer service or check the member benefit booklet for specific benefit limitations and effective-date applicability.
Coverage depends on the member's contract and the date of service.

Billing Rule

Coding Accuracy and Effective-Date Risk

Use current, effective CPT and HCPCS codes for the date of service. Claims billed with codes that were not effective on the date of service or that are otherwise incorrect may be denied.

Confirm the correct code effective dates (examples: codes effective 07/01/25 and 01/01/26 are listed in the coding sections).
Claims using codes removed from policy or not recognized for the date of service risk denial.

Denial Risk

Investigational Services — Denial Risk

Services meeting the policy definition of experimental or investigational may be denied. Examples include devices or drugs without FDA approval for the intended use, services subject to IRB oversight, or services lacking reliable peer-reviewed evidence of effectiveness.

If a service is part of an ongoing clinical trial or lacks reliable evidence of effectiveness, coverage is not established and claims may be denied.
Review published peer-reviewed literature and Plan determinations when preparing documentation and appeals.

Documentation Required

Documentation Guidance

Providers should document clinical rationale, diagnostic findings, prior conservative therapies, and citations to relevant literature when requesting coverage determinations or submitting appeals. Refer to the specific policy listings and the member's contract to determine coverage.

Documentation should support medical necessity and show how the service differs from investigational criteria where applicable.
When requesting PA, include operative reports, device details, and pertinent imaging or test results.

Documentation Required

Documentation Requirements — None Specified in Coding Sections

No additional, specific documentation requirements are listed in the coding blocks of this policy. Follow standard medical record documentation practices and any PA submission instructions provided by the Plan.

The coding sections list many temporary and new CPT/HCPCS codes but do not specify unique documentation checklists.
Always follow plan-specific prior authorization forms and instructions if PA is required.

Note

Code Description Attribution

CPT and HCPCS code descriptions in this policy are sourced from the AMA and CMS. Maintain accurate code descriptions on claims and respect AMA/CMS copyright notices.

"CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS)."
Ensure code descriptions on claims match current AMA/CMS descriptions for the date of service.

Examples in the coding section include assistive ECG analyses (e.g., 0764T, 0765T, 0962T) and augmentative imaging analyses (e.g., 0899T, 0900T).

Use caseThese codes describe software-driven analyses that generate diagnostic or risk-assessment outputs to aid clinician interpretation, not stand-alone definitive diagnoses.

Experimental/Investigational — Contract applicability

Contract consistencyDefinitions of 'experimental/investigational' are provided as summarized from most benefit contracts; applicability depends on the member's specific health benefit plan contract.

RecommendationConsult the applicable health benefit plan contract to determine the exact definition and applicability for a given member.

Policy roleThis policy lists services typically considered investigational as a general reference and is not exhaustive; separate policies may list additional investigational services.

Experimental or Investigational — Criteria and implications

General ruleServices are considered experimental/investigational when they meet one or more established criteria such as lacking FDA approval, being subject to IRB oversight, lacking reliable evidence of effectiveness, being the subject of ongoing clinical trials, or requiring additional research before they can be considered as effective as conventional therapies.

ConsequencesServices meeting these criteria are typically categorized as investigational and are therefore not covered under this policy unless specific contract language dictates otherwise.

Evidence standardReliable evidence includes peer-reviewed medical literature and Blue Cross Blue Shield Center for Clinical Effectiveness assessments.

Added numerous new CPT codes (0990T–1018T series and others) and selected CPT/HCPCS codes (e.g., 27458, 27713, 75577) effective January 1, 2026; several codes (0619T, 0623T–0626T) were slated as termed effective January 1, 2026.

2025-07-01coding_update

Added many new CPT codes (e.g., 0948T–0987T series including 0956T–0960T and 0961T–0962T) due to Q3 coding updates effective July 1, 2025.

2024-12-01coding_update

Removed HCPCS 0376U from this policy (moved to another policy) and scheduled policy changes effective March 5, 2025; added CPT code 92972.

2024-07-01coding_update

Added new CPT codes 0867T–0875T, 0877T–0900T and 93895 effective July 1, 2024.

2023-07-01coding_update

Coding update added multiple CPT and HCPCS codes (examples include 0393U, 0395U, 0793T–0808T and C9785/C9787) effective July 1, 2023.

No additional documentation requirements are specified in these coding-focused chunks. This placeholder is included for completeness; providers should follow any documentation rules specified in the Plan’s general policy instructions or in other related policies.

Be aware of code effective dates when submitting claims. Claims using codes that are not recognized or not effective for the date of service may be denied; verify the correct newly effective CPT/HCPCS code and applicable effective date to reduce the risk of claim denials.