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Currentpremera-bluecrossPolicy 10.01.533_HMO

Non-covered Experimental/Investigational Services

Defines services, procedures, devices, and codes considered experimental or investigational per Premera Blue Cross benefit contracts and provides the long and evolving list of CPT/HCPCS/HCPCs/C codes that are considered investigational. Includes definition criteria and extensive coding updates/history.

Policy Summary

Payerpremera-bluecross

PolicyNon-covered Experimental/Investigational Services

Policy CodePolicy 10.01.533_HMO

Change TypeCoding additions and reorganizations

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders should consult the applicable health benefit plan contract for the specific definition of experimental/investigational and expect denial for listed codes unless a plan-specific exception applies.

SourceLink

POLICY UPDATE CHANGES

Numerous CPT and HCPCS codes were added with various effective dates (07/01/25, 01/01/26, 10/01/25, etc.) as listed in the coding sections.

Added multiple new CPT codes effective 01/01/26 (0990T-1018T and several other CPT and standard codes) and indicated some codes termed effective 01/01/26.

Definition of experimental/investigational services provided as a list of criteria used to determine investigational status.

10/01/24 annual review: no changes to policy statements but numerous HCPCS codes added and some moved to other policies.

03/01/25 coding update moved many CPT codes to other policies and removed CPT 25448.

100+Listed investigational codes in this part

2021-2026History coverage (years of updates shown)

multipleNew codes effective 01/01/26 in this part

200+Codes listed (approx.)

MultipleCodes moved to other policies

unchangedAnnual review 10/01/24 & 10/01/25

Coverage Summary

Overview: This policy (status: CURRENT) defines services, procedures, devices, supplies and the CPT/HCPCS/C codes that the Plan considers experimental or investigational and therefore not covered. Effective date entries shown in the document header include Oct. 1, 2025 and Mar. 1, 2026; the policy’s documented last review/annual review notes include 10/01/24 and 10/01/25.

High-level statement: Any service, procedure, device or supply represented by CPT or HCPCS codes listed in this policy is considered experimental/investigational and not covered under this policy unless those codes have been reassigned and are governed by another specific policy; codes that were moved are governed by their destination policies. Note: Medicare Advantage is not governed by this policy (the policy does not apply to Medicare Advantage).

Key summary

Listed investigational codes in this part100+

Codes listed (approx.)200+

History coverage (years)2021-2026

New codes effective 01/01/26

Policy Summary

Payerpremera-bluecross

PolicyNon-covered Experimental/Investigational Services

Policy CodePolicy 10.01.533_HMO

Change TypeCoding additions and reorganizations

Effective DateMar 1, 2026

Next Review DateN/A

SourceLink

On This Page

Definitions

Definitions: Experimental or Investigational — a service (treatment, procedure, equipment, drug, device, or supply) that meets one or more criteria such as lacking FDA approval for the intended use, being subject to Institutional Review Board oversight, lacking reliable evidence of effectiveness, being the subject of ongoing clinical trials (safety/efficacy/toxicity), or where evaluation of evidence indicates additional research is needed before it can be considered as effective as conventional therapies.

Reliable evidence — reports and articles published in authoritative peer‑reviewed medical and scientific literature and assessments and coverage recommendations published by the Blue Cross and Blue Shield Center for Clinical Effectiveness.

Term date — the date when a CPT/HCPCS code is no longer effective and thus removed/termed in the policy.

Medical-Necessity Criteria

Definition of Experimental or Investigational

Experimental or investigational services include a treatment, procedure, equipment, drug, drug usage, medical device, or supply that meets one or more of the following criteria:

ANY of the following

A drug or device that cannot be lawfully marketed without the approval of the US Food and Drug Administration and has not been granted such approval on the date the service is provided.
The service is subject to oversight by an Institutional Review Board.
No reliable evidence demonstrates that the service is effective in clinical diagnosis, evaluation, management, or treatment of the condition.
The service is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety, or efficacy.
Evaluation of reliable evidence indicates that additional research is necessary before the service can be classified as equally or more effective than conventional therapies.

Non-covered / Experimental or Investigational Services - general

Services, procedures, supplies, devices and codes listed in this policy are considered experimental/investigational and are non-covered under this policy unless otherwise specified by another policy or benefit:

ALL of the following

Any service, procedure, device or supply represented by CPT or HCPCS codes listed in this policy is considered non-covered as experimental/investigational.
Codes moved to other policies are governed by those destination policies (refer to specific destination policy for coverage criteria).
Refer to the specific policy where codes were reassigned for coverage criteria.
This policy does not replace member contract language; consult the member benefit booklet or customer service for plan-specific coverage. This medical policy does not apply to Medicare Advantage.
Member benefit booklet or customer service should be consulted for plan-specific coverage.

Coding (codes listed as investigational / non-covered)

Listed CPT codes considered investigational (present in this part)CPTNot Covered

0906T	Concurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; first application, total wound(s) surface area less than or equal to 50 sq cm.
0907T	Concurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; each additional application, total wound(s) surface area less than or equal to 50 sq cm (List separately in addition to code for primary procedure).
0908T	Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed.
0909T	Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed.
0910T	Removal of integrated neurostimulation system, vagus nerve.
0911T	Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional.
0912T	Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional.
0913T	Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon (e.g., drug-coated, drug-eluting), including mechanical dilation by nondrug-delivery balloon angioplasty, endoluminal imaging using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) when performed, imaging supervision, interpretation, and report, single major coronary artery or branch.
0914T	Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon performed on a separate target lesion from the target lesion treated with balloon angioplasty, coronary stent placement or coronary atherectomy, including mechanical dilation by nondrug-delivery balloon angioplasty, endoluminal imaging using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) when performed, imaging supervision, interpretation, and report.
0915T	Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous.

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Listed HCPCS / C / E / A / G / L / P / S codes considered investigational (present in this part)mixedNot Covered

A4468	Exsufflation belt, includes all supplies and accessories.
A4544	Electrode for external lower extremity nerve stimulator for restless legs syndrome.
A4593	Neuromodulation stimulator system, adjunct to rehabilitation therapy regime.
A4594	Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece each.
A7023	Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical.
A7049	Expiratory positive airway pressure intranasal resistance valve (ULTepap).
A9615	Injection, pegulicianine, (Lumisight) 1 mg.
C1052	Hemostatic agent, gastrointestinal, topical (Hemospray).
C1607	Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system (used to report the SetPoint System).
C1735	Catheter(s), intravascular for renal denervation, radiofrequency.

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Non-covered / Experimental HCPCS codes (explicitly added/removed over time)HCPCSNot Covered

C1607	HCPCS code added 03/01/26; considered non-covered.
C9761	Added 01/01/26; considered non-covered.
C1742	Added 10/01/25 (new code effective 10/01/25).
C9781	Added 05/01/24 (coding update added HCPCS code C9781).
C9785	Added 07/01/23 (coding update).
C9787	Added 07/01/23; termination date later added (term date added 07/01/24).
C9789	Added 10/01/23 (coding update).
C9790	Added 10/01/23; termination date later added.
C9792	Added 10/01/23 (coding update).
C1832	Removed from this policy (on policy 7.01.113) as of 12/01/23.

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Non-covered / Experimental CPT codes (explicitly added/removed over time)CPTNot Covered

0673T	Listed in document header (added 06/01/22 coding update).
0206U	Removed 07/01/22.
0207U	Removed 07/01/22.
0327U	Noted historical movements (present as example).
0337U	Added 01/01/23; later moved 03/01/25 to policy 2.04.520.
0338U	Added 01/01/23; later moved 03/01/25 to policy 2.04.520.
0342U	Added 01/01/23; later moved 03/01/25 to policy 2.04.520.
0344U	Added 01/01/23; later moved 03/01/25 to policy 2.04.520.
0357U	Added 02/01/23; later moved 03/01/25 to policy 2.04.520.
0358T	Removed (moved to policy 6.01.528).

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Other CPT/HCPCS codes historically referenced or movedmixed

25448	Removed 03/01/25 (removed in coding update).
25448	Removed 03/01/25 (duplicate entry historically).
27278	Removed 03/01/24 as on other policies.
88305	Removed 03/01/24 as on other policies.
88312	Removed 03/01/24 as on other policies.
27458	Added 01/01/26 (new code effective 01/01/26).
27713	Added 01/01/26 (new code effective 01/01/26).
52443	Added 01/01/26 (new code effective 01/01/26).
75577	Added 01/01/26 (new code effective 01/01/26).
94470	Added 01/01/26 (new code effective 01/01/26).

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Provider Actions

Denial Risk

Investigational services not covered

Services listed in this policy are considered experimental/investigational and are not covered under this policy. Providers should expect denial or noncoverage when billing the listed CPT, HCPCS, and C codes unless a plan-specific exception or different contract language applies.

Listed CPT codes (many codes throughout the coding sections, e.g., 0906T–1018T, 27458, 27713, etc.)
Listed HCPCS/C codes (e.g., C1607, C9761, C1742, C1761, etc.)
Codes recently added with effective dates 07/01/25 and 01/01/26 (see coding sections)

Documentation Required

Reference benefit contract

Consult the applicable health benefit plan contract for the specific definition of experimental/investigational. The policy provides common definitions for reference, but the member's contract language governs coverage determinations.

Documentation Required

Check member benefit booklet / customer service

Confirm plan-specific coverage, benefit limitations, and whether any exceptions apply by checking the member benefit booklet or contacting customer service prior to providing or billing services listed in this policy.

Billing Rule

Follow destination policy for moved codes

When codes listed in this policy have been reassigned or moved to other medical policies, follow the coverage and billing requirements in the destination policy rather than this policy.

Examples of destination policies: 2.04.520, 2.04.521, 1.01.507, 2.01.526

Background

Background/Purpose: This document serves as a coding‑based noncoverage list identifying services the Plan has determined to be experimental or investigational. The policy purpose is to list codes representing services for which safety and/or effectiveness have not been established.

How reliability is judged: Determinations rely on review of the published peer‑reviewed medical and scientific literature and on recognized assessments and coverage recommendations (examples include reviews by the Blue Cross and Blue Shield Center for Clinical Effectiveness).

Updates: The coding list is maintained and periodically updated (coding additions, term dates, and movements of codes to other policies are documented in the history and coding sections); when codes are moved to other policies, those destination policies govern coverage going forward.

Revision History

07/01/25revised

Numerous CPT and HCPCS codes were added with various effective dates (07/01/25, 01/01/26, 10/01/25, etc.) as listed in the coding sections.

01/01/26revisedLatest

Added multiple new CPT codes effective 01/01/26 (0990T-1018T and several other CPT and standard codes) and indicated some codes termed effective 01/01/26.

10/01/24clarified

10/01/24 annual review: no changes to policy statements but numerous HCPCS codes added and some moved to other policies.

03/01/25revised

03/01/25 coding update moved many CPT codes to other policies and removed CPT 25448.

03/01/26revised

HCPCS C1607 added 03/01/26 (coding update reflecting movement of C1607).