CurrentUnitedHealthcarePolicy N/A

Omnibus Codes (for Kansas Only) / Medical Policy (Part of UnitedHealthcare Medical Policy — coverage determinations for multiple technologies)

Part 2 of a UnitedHealthcare medical policy enumerating coverage determinations and clinical evidence summaries for multiple procedures, devices, and laboratory tests; this section declares several listed services and codes as unproven and not medically necessary and provides supporting clinical evidence and references.

Policy Summary

PayerUnitedHealthcare

PolicyOmnibus Codes (for Kansas Only) / Medical Policy (Part of UnitedHealthcare Medical Policy)

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (codes added, revised, removed)

Effective DateFeb 1, 2026

Next Review Date

Key ActionClaims for the listed codes/services in this part should be considered not medically necessary; providers should expect denial if these unproven services are submitted without clinical justification consistent with accepted indications.

POLICY UPDATE CHANGES

Added notation that bracketed language following unlisted code descriptions was added by UnitedHealthcare to indicate intended code use within this policy.

Added coverage guidelines for Histotripsy (CPT codes 0686T and 0888T) indicating histotripsy is unproven and not medically necessary for treating malignant liver and renal tumors.

Added coverage guidelines for oncology quantitative ELISA (CPT codes 0558U and 0559U) indicating use to monitor therapy/disease progression is unproven and not medically necessary.

Revised coverage guideline language for ablative laser treatment for wound healing (CPT 17999) to narrow excluded techniques to 'full field and fractional ablation' rather than including 'non-contact'.

Added coverage guidelines indicating histotripsy (CPT 0686T, 0888T) is unproven and not medically necessary for treating malignant liver and renal tumors.

Added language that oncology quantitative ELISA (CPT 0558U, 0559U) for protein biomarkers to monitor therapy/disease progression is unproven and not medically necessary.

Revised coverage guideline wording for ablative laser treatment for wound healing (CPT 17999) to specify full field and fractional ablation are unproven and not medically necessary.

Revised language for bronchoscopic treatment of bronchopleural/bronchoalveolar fistulas with an occlusive substance (CPT 31634) to add guidance for members under 18 years of age.

Removed language indicating future RCTs are warranted for cardiac contractility modulation (CPTs 0408T-0418T, K1030).

Replaced generic optical endomicroscopy language with confocal laser endomicroscopy (CLE) terminology and specified CLE is unproven and not medically necessary (CPTs 0397T, 43206, 43252, 88375).

Added HCPCS code G0555 to Implantable Wireless PAP Sensor listing and added 'Cordella' to examples of devices.

Removed CPT 84999 from laboratory measurement of antidrug antibodies and serum levels of biologic agents and biosimilars list.

Replaced laboratory measurement coverage statement to specify conditions for which measurement for assessing treatment response is unproven and not medically necessary.

Replaced language regarding remote monitoring of an external continuous pulmonary fluid monitoring system to indicate transmission of data to a qualified health care professional is unproven.

Revised descriptions for transcutaneous magnetic stimulation (tMS) CPT codes 0766T and 0767T and updated language on FDA approval of electromagnetic stimulator devices for pain relief.

Removed coverage guidelines (no longer require clinical review) for multiple codes including 86849, 58999, 29799, 97139, 97799, A9999, 76999, and 30999.

Updated applicable CPT/HCPCS code lists for Radiofrequency Ablation for Joint Pain, Radiofrequency Therapy, Robotic Lower Body Exoskeleton Devices, and Ultrafiltration (Aquapheresis).

Updated Clinical Evidence and References sections to reflect current information.

8Unproven items listed in this part

multipleClinical evidence summaries provided

variousProcedures explicitly not medically necessary

FDA 2023Regulatory actions noted

Jan 2025Device recall mentioned

Coverage Summary & Scope

Medical Necessity / Coverage Criteria (By Topic)

Unproven / Not Medically Necessary Items in this Part

The following items in this part are considered Unproven / Not Medically Necessary based on the available evidence and are therefore not covered.

Transcutaneous measurement of five biomarkers using spatial frequency domain imaging and multi-spectral analysis (0061U) — Unproven.

Transcatheter placement of extracranial vertebral artery stent(s) (0075T, 0076T) — Unproven.

Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array (0100T) — Unproven.

Oncology (colorectal) screening biochemical ELISA of 3 plasma or serum proteins with proprietary algorithm (0163U) — Unproven.

Policy Summary

PayerUnitedHealthcare

PolicyOmnibus Codes (for Kansas Only) / Medical Policy (Part of UnitedHealthcare Medical Policy)

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (codes added, revised, removed)

Effective DateFeb 1, 2026

Next Review Date

On This Page

Computer-aided detection (CAD) for chest radiograph(s) (0174T, 0175T) — Unproven.

Evacuation of meibomian glands, automated, using heat and intermittent pressure (0207T) — Unproven.

Automated pure tone and speech audiometry (0208T, 0209T, 0210T, 0211T, 0212T) — Unproven.

Transluminal peripheral atherectomy (renal, visceral except renal, abdominal aorta, brachiocephalic trunk) (0234T, 0235T, 0236T, 0237T) — Unproven.

PreTRM serum-based proteomic test (IBP4/SHBG) for prediction of spontaneous preterm birth (0247U) — Unproven.

Carotid sinus baroreflex activation device implantation/interrogation/programming/revision (0266T–0273T) — Unproven.

Tear film imaging (0330T) — Unproven.

Myocardial sympathetic innervation imaging (I-123 MIBG) planar and SPECT (0331T, 0332T) — Unproven.

Automated visual evoked potential (0333T) — Unproven.

Insertion of sinus tarsi implant (0335T) — Unproven.

Transcatheter renal sympathetic denervation (0338T, 0339T) — Unproven.

Radiostereometric analysis (RSA) placement and radiologic examination (0347T–0350T) — Unproven.

Bioelectrical impedance analysis whole body composition assessment (0358T) — Unproven.

High dose rate electronic brachytherapy, skin surface and interstitial/intracavitary (0394T, 0395T) — Unproven.

Endoscopic optical endomicroscopy during ERCP (0397T) — Unproven.

Cardiac Contractility Modulation (insertion/replacement/removal codes 0408T–0413T) — Unproven.

Tear film imaging CPT 0330T (coverage stance captured above) — Unproven.

I-123 MIBG myocardial sympathetic innervation imaging (0331T/0332T) for prognostic use in heart failure — Unproven.

Automated VEPs (0333T) for vision screening — Unproven.

Sinus tarsi implant / Subtalar arthroereisis (0335T) — Unproven.

Renal denervation (0338T/0339T) — Unproven.

Radiostereometric analysis (0347T–0350T) — Unproven.

Bioelectrical impedance analysis (0358T) — Unproven.

Electronic brachytherapy (0394T/0395T) — Unproven.

Confocal/Optical Endomicroscopy (0397T) — Unproven.

Confocal Laser Endomicroscopy (CLE) - General conclusions: insufficient evidence to support routine use — Unproven.

Cardiac Contractility Modulation (CCM) - Coverage Position: Unproven.

Percutaneous Cryoablation/Cryoneurolysis for chronic pain and knee osteoarthritis (iovera System) — Unproven.

Drug-eluting ocular inserts (e.g., bimatoprost inserts) — Unproven.

Optical coherence tomography (OCT) for middle ear — Unproven.

Macular pigment optical density (MPOD) measurement by heterochromatic flicker photometry (HFP) — Unproven.

Near-infrared dual imaging of meibomian glands; AC-powered meibography devices — Unproven.

Wireless LV endocardial CRT (WiSE CRT System) — Unproven.

Intracardiac ischemia monitoring systems (e.g., Guardian/Avertix/AngelMed) — Unproven.

Oncology quantitative ELISA protein biomarker panels (IGoCheck BF7, MammoCheck BF9) — Unproven.

Three-dimensional (3D) printed anatomic models and 3D-printed implants/guides — Unproven.

Coverage/Medical Necessity Statements referenced in this part reflect the Unproven determinations above.

Covered vs Not Covered determinations in this section: items listed as "Unproven" are considered not medically necessary and not covered.

Coverage determinations inferred from evidence summaries: where evidence is insufficient or conflicting, the device/test/procedure is Unproven.

Eye tracking (EyeBox/Oculogica) — Unproven.

Hyperspectral imaging (HSI) — Unproven.

Near-infrared spectroscopy (NIRS) including for acute compartment syndrome (ACS) — Unproven.

Percutaneous ultrasound gastrostomy (PUG/PUMA-G) — Unproven.

Magnetically controlled capsule endoscopy (MCCE/MCCG/Navicam) — Unproven.

Electrical impedance spectroscopy (EIS/Nevisense) for automated melanoma risk scoring — Unproven.

Nevisense (EIS) — Unproven in implied coverage context.

SSO2 Therapy (TherOx DownStream System) — Unproven.

Uterus Transplantation (UTx) — Unproven.

Radiofrequency and other vaginal energy-based therapies for SUI and vulvo-vaginal laxity (including CMRF/Viveve) — Unproven.

Transurethral/Transvaginal Radiofrequency devices for female SUI and laxity — Unproven.

Histotripsy for malignant liver and renal tumors — Unproven.

Therapeutic Ultrafiltration (Aquapheresis/Aquadex) for fluid overload/acute decompensated heart failure — Unproven.

Three-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue (3D breast imaging) — Unproven.

Alfapump (automated low-flow ascites pump) — evidence summary suggests investigational use; Unproven.

Ablative laser treatment for wound healing — Unproven.

Intraoperative radiation therapy (IORT) — Unproven for many indications; see evidence summaries.

RFA for joint pain — Unproven for specified joint pain indications.

Bronchoscopy with balloon occlusion and occlusive substance (adults) — Unproven.

Bronchoscopic treatment of bronchopleural or bronchoalveolar fistulas (pediatric) — Unproven.

Implantable wireless pulmonary artery (PAP) sensor (CardioMEMS/Cordella) — Unproven for indications listed.

CardioMEMS / Hemodynamic-guided PAP monitoring — evidence summary does not support broad coverage; Unproven.

Periurethral transperineal adjustable balloon continence devices (ProACT/ACT) — Unproven.

UroCuff penile cuff test — Unproven.

MRgFUS statements in this part: where listed as Unproven, considered not medically necessary.

Noninvasive tests for bladder outlet obstruction (BOO) — evidence summary does not support routine coverage; Unproven.

Surgical treatment of sacral perineural (Tarlov) cysts — medically necessary criteria exist (see separate group); other indications Unproven.

Genicular Nerve Block (GNB) — Not Medically Necessary / Unproven.

Insertion of Iris Prosthesis (CustomFlex Artificial Iris) — Not Medically Necessary / Unproven for listed indications.

MRI-guided focused ultrasound subthalamotomy/thalamotomy for Parkinson disease/essential tremor — coverage context: Unproven for routine coverage.

Not medically necessary / Unproven indications described throughout this part are captured above.

NICE guidance for artificial iris (AI) insertion does not change Unproven determination in this policy context.

Coverage position for MBDA (Vectra) test — Unproven for routine clinical use.

Therapeutic drug monitoring (TDM) for biologics in IBD — see clinical guidance summaries; outside listed indications Unproven.

MBDA (Vectra) testing — evidence summary and implication: Unproven.

Spirometry and pulmonary function testing in children under age three — Not routinely covered / Unproven.

Robotic lower body exoskeleton devices for ambulation assistance and RAGT — Unproven.

Exoskeleton / Robot-assisted gait training (RAGT) — evidence summary does not support routine coverage; Unproven.

External upper limb tremor stimulators (Cala TAPS) — Unproven.

Female external urinary collection devices — Unproven.

Three-dimensional printed cranial implants — Unproven.

Powered upper extremity orthosis (MyoPro) — Unproven for routine coverage.

Hair analysis — Unproven.

Unlisted code description note: where unlisted codes are used for technologies above, the Unproven coverage conclusion applies.

Automated / Self-Administered Audiometry

Automated / Self-Administered Audiometry (pure tone and speech) — Position: Unproven / Not Medically Necessary.

Pure tone audiometry (threshold), automated; air only (0208T) — Unproven.

Pure tone audiometry (threshold), automated; air and bone (0209T) — Unproven.

Speech audiometry threshold, automated (0210T) — Unproven.

Speech audiometry threshold, automated; with speech recognition (0211T) — Unproven.

Comprehensive automated audiometry (0209T and 0211T combined) (0212T) — Unproven.

Policy conclusion: Automated or self-administered audiometry methods lack sufficient evidence demonstrating equivalence to standard diagnostic audiology performed by qualified professionals for clinical decision-making; therefore these automated services are considered not medically necessary.

Transluminal Peripheral Atherectomy (visceral, renal, abdominal, brachiocephalic arteries)

Transluminal peripheral atherectomy in visceral, renal, abdominal aorta, and brachiocephalic arteries — Position: Unproven / Not Medically Necessary.

Transluminal peripheral atherectomy, renal artery (0234T) — Unproven.

Transluminal peripheral atherectomy, visceral artery (except renal), each vessel (0235T) — Unproven.

Transluminal peripheral atherectomy, abdominal aorta (0236T) — Unproven.

Transluminal peripheral atherectomy, brachiocephalic trunk and branches, each vessel (0237T) — Unproven.

Policy conclusion: The available evidence is insufficient to establish the safety and effectiveness of transluminal peripheral atherectomy in renal, visceral, abdominal aortic, or brachiocephalic locations for routine clinical use; therefore these procedures are considered not medically necessary.

PreTRM Serum-Based Proteomic Test (IBP4/SHBG)

PreTRM Serum-Based Proteomic Test (IBP4/SHBG) — Position: Unproven / Not Medically Necessary.

Obstetrics (preterm birth) IBP4/SHBG quantitative measurement by LC-MS/MS utilizing maternal serum with clinical data (0247U) — Unproven.

Policy conclusion: The preTRM proteomic test (IBP4/SHBG) has insufficient evidence to demonstrate clinically meaningful improvement in maternal or neonatal outcomes when used for prediction of spontaneous preterm birth; therefore it is considered not medically necessary.

Carotid Sinus Baroreflex Activation Devices (BAT)

Carotid Sinus Baroreflex Activation Devices (Baroreceptor Stimulation/BAT): Coverage stance and clinical evidence summary — Unproven / Not Medically Necessary.

Implantation or replacement of carotid sinus baroreflex activation device; total system (0266T) — Unproven.

Implantation or replacement; lead only, unilateral (0267T) — Unproven.

Implantation or replacement; pulse generator only (0268T) — Unproven.

Revision or removal; total system (0269T) — Unproven.

Revision or removal; lead only, unilateral (0270T) — Unproven.

Revision or removal; pulse generator only (0271T) — Unproven.

Interrogation device evaluation (in person), carotid sinus baroreflex activation system (0272T) — Unproven.

Interrogation device evaluation with programming (0273T) — Unproven.

Clinical evidence summary: Current published evidence for carotid sinus baroreflex activation devices (BAT) is limited, with inconsistent results across trials and insufficient high-quality data demonstrating long-term clinical benefit in target populations. Risks related to implantation and device therapy and lack of reproducible outcome improvement support a conclusion of investigational/unproven.

Tear film imaging (CPT 0330T)

Tear film imaging (CPT 0330T) — Coverage stance.

Tear film imaging, unilateral or bilateral, with interpretation and report (0330T) — Unproven.

Policy conclusion: Tear film imaging technology lacks sufficient evidence of diagnostic accuracy and impact on patient outcomes to support routine coverage; considered not medically necessary.

I-123 MIBG imaging

I-123 MIBG myocardial sympathetic innervation imaging (0331T, 0332T) — Coverage stance and specific prognostic use.

Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment (0331T) — Unproven.

Myocardial sympathetic innervation imaging, with tomographic SPECT (0332T) — Unproven.

I-123 MIBG myocardial scintigraphy — prognostic use in heart failure: Current evidence is insufficient to support routine clinical use of I-123 MIBG imaging for prognostic stratification in heart failure patients; therefore these imaging services are considered not medically necessary.

Automated VEPs

Automated Visual Evoked Potentials (VEPs) for vision screening (0333T) — Position: Unproven / Not Medically Necessary.

Visual evoked potential, screening of visual acuity, automated, with report (0333T) — Unproven.

Policy conclusion: Automated VEP screening lacks sufficient evidence showing reliable diagnostic performance and effect on management compared with standard ophthalmologic/optometric evaluation; considered not medically necessary.

Sinus tarsi implant

Sinus tarsi implant / Subtalar arthroereisis (0335T) — Position: Unproven / Not Medically Necessary.

Insertion of sinus tarsi implant (0335T) — Unproven.

Policy conclusion: Evidence for sinus tarsi implant/subtalar arthroereisis is limited and inconclusive regarding long-term outcomes and comparative benefit; therefore considered not medically necessary.

Renal denervation

Transcatheter renal sympathetic denervation (RDN) (0338T, 0339T) — Coverage stance and evidence summary.

Transcatheter renal sympathetic denervation, unilateral (0338T) — Unproven.

Transcatheter renal sympathetic denervation (0339T) — Unproven.

Renal denervation clinical evidence summary: Trials to date have produced mixed results with inconsistent blood pressure lowering compared with sham or medical therapy and limited long-term outcome data; safety and effectiveness have not been sufficiently established for routine coverage.

Radiostereometric analysis (RSA)

Radiostereometric analysis (RSA) placement and radiologic examination (0347T–0350T) — Position: Unproven / Not Medically Necessary.

Placement of interstitial device(s) in bone for radiostereometric analysis (0347T) — Unproven.

RSA radiologic examination: spine (0348T) — Unproven.

RSA radiologic examination: upper extremity (0349T) — Unproven.

RSA radiologic examination: lower extremity (0350T) — Unproven.

Policy conclusion: RSA techniques remain investigational for routine clinical use and lack established impact on clinical decision-making across most indications; considered not medically necessary.

Bioelectrical impedance analysis (BIA)

Bioelectrical impedance analysis (BIA) whole body composition assessment (0358T) — Position: Unproven / Not Medically Necessary.

Bioelectrical impedance analysis whole body composition assessment, with interpretation and report (0358T) — Unproven.

Policy conclusion: BIA devices and services have variable accuracy compared with reference methods and insufficient evidence demonstrating improved clinical outcomes when used for body composition assessment in routine care; considered not medically necessary.

High dose rate electronic brachytherapy (EBT)

High dose rate electronic brachytherapy (EBT) — Position: Unproven / Not Medically Necessary for listed CPT codes.

High dose rate electronic brachytherapy, skin surface application, per fraction (0394T) — Unproven.

High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction (0395T) — Unproven.

Policy conclusion: EBT modalities lack sufficient comparative evidence demonstrating equivalent or superior outcomes versus standard brachytherapy or external beam approaches for many indications; considered not medically necessary.

Confocal/Optical Endomicroscopy (CLE/optical endomicroscopy)

Confocal/Optical Endomicroscopy (CLE/pCLE/optical endomicroscopy) during endoscopic procedures — Position: Unproven / Not Medically Necessary.

Endoscopic optical endomicroscopy during ERCP (0397T) — Unproven.

Confocal/Optical Endomicroscopy - General conclusions: Current evidence is insufficient to demonstrate consistent diagnostic benefit or impact on patient outcomes to support routine coverage; considered not medically necessary.

Cardiac Contractility Modulation (CCM)

Cardiac Contractility Modulation (CCM) — Coverage Position.

Insertion or replacement of CCM system total system (0408T) — Unproven.

Insertion or replacement; pulse generator only (0409T) — Unproven.

Insertion or replacement; atrial electrode only (0410T) — Unproven.

Insertion or replacement; ventricular electrode only (0411T) — Unproven.

Removal of CCM system; pulse generator only (0412T) — Unproven.

Removal of CCM system; transvenous electrode (0413T) — Unproven.

Policy conclusion: CCM devices and related procedures lack sufficient high-quality evidence demonstrating clinically meaningful improvements in mortality or hospitalization across indicated populations; considered not medically necessary.

Cryoneurolysis / iovera system

Percutaneous cryoablation / Cryoneurolysis (including iovera System) for chronic pain and knee osteoarthritis — Position: Unproven / Not Medically Necessary.

Percutaneous cryoneurolysis / iovera system for chronic pain or knee osteoarthritis — Unproven.

Policy conclusion: Evidence for percutaneous cryoneurolysis devices is limited with variable outcomes and insufficient data on long-term benefit and harms; considered not medically necessary.

Drug-eluting ocular inserts

Drug-eluting ocular inserts (e.g., bimatoprost inserts) — Position: Unproven / Not Medically Necessary.

Drug-eluting ocular inserts for glaucoma or ocular surface disease — Unproven.

Policy conclusion: Clinical evidence is insufficient to support routine coverage of drug-eluting ocular inserts for the management of glaucoma or other ocular conditions; considered not medically necessary.

Middle ear OCT

Optical coherence tomography (OCT) for the middle ear — Position: Unproven / Not Medically Necessary.

Middle ear OCT — Unproven.

Policy conclusion: OCT imaging of the middle ear lacks sufficient evidence demonstrating diagnostic accuracy and impact on management compared with standard otologic evaluation; considered not medically necessary.

MPOD HFP

Macular Pigment Optical Density (MPOD) measurement by heterochromatic flicker photometry (HFP) — Position: Unproven / Not Medically Necessary.

MPOD measurement by HFP — Unproven.

Policy conclusion: Insufficient evidence that MPOD HFP measurement improves clinical outcomes or management decisions in routine ophthalmic care; considered not medically necessary.

Meibomian imaging

Meibomian gland imaging and meibography devices — Position: Unproven / Not Medically Necessary.

Near-infrared dual imaging of meibomian glands — Unproven.

AC-powered meibography devices (diagnostic imaging devices for MGD) — Unproven.

Policy conclusion: Meibography and related imaging technologies have limited evidence that results change management or improve outcomes beyond clinical examination; considered not medically necessary.

WiSE CRT

Wireless LV endocardial CRT (WiSE CRT System) — Position: Unproven / Not Medically Necessary.

Wireless LV endocardial CRT (WiSE CRT) — Unproven.

Policy conclusion: Evidence is insufficient to support routine adoption of wireless LV endocardial CRT systems for standard CRT candidates; considered not medically necessary.

Intracardiac ischemia monitoring

Implantable intracardiac ischemia monitoring systems (e.g., Guardian/Avertix/AngelMed) — Position: Unproven / Not Medically Necessary.

Intracardiac ischemia monitoring systems — Unproven.

Policy conclusion: Current evidence does not demonstrate clear benefit in outcomes from routine use of implantable intracardiac ischemia monitors; considered not medically necessary.

Oncology quantitative ELISA panels

Oncology quantitative ELISA protein biomarker panels (IGoCheck BF7, MammoCheck BF9, others) — Position: Unproven / Not Medically Necessary.

Oncology ELISA panels for colorectal or breast cancer screening (e.g., IGoCheck BF7, MammoCheck BF9, 0163U) — Unproven.

Policy conclusion: These proprietary ELISA biomarker panels lack sufficient validation and evidence of clinical utility for screening or prognostication; considered not medically necessary.

3D printed anatomic models

Three-dimensional (3D) printed anatomic models and 3D-printed implants/guides — Position: Unproven / Not Medically Necessary for routine use.

3D printed anatomic models and 3D-printed implants/guides — Unproven.

Policy conclusion: While potentially useful in select cases, routine use of 3D printed models/guides lacks consistent evidence of improved outcomes and is considered investigational for general coverage.

Coverage determinations and related statements referenced in this part

Coverage/Medical Necessity Statements, Covered vs Not Covered determinations, and Coverage determinations inferred from evidence summaries in this part — Consolidated conclusions: items listed as Unproven are not medically necessary.

Coverage/Medical Necessity Statements referenced above reflect the Unproven status of listed items.

Covered vs Not Covered determinations: Procedures/tests/devices designated "Unproven" are considered not medically necessary and not covered.

Coverage determinations inferred from evidence summaries: when evidence is inadequate or inconsistent, items are categorized as Unproven and therefore not covered.

Additional Unproven Items referenced in this part

Additional technologies and tests with an Unproven / Not Medically Necessary determination in this part.

Eye tracking systems (EyeBox/Oculogica) — Unproven.

Hyperspectral imaging (HSI) — Unproven.

Near-infrared spectroscopy (NIRS), including use for acute compartment syndrome (ACS) — Unproven.

Percutaneous ultrasound gastrostomy (PUG/PUMA-G) — Unproven.

Magnetically controlled capsule endoscopy (MCCE/MCCG/Navicam) — Unproven.

Electrical impedance spectroscopy (EIS/Nevisense) for automated melanoma risk scoring — Unproven.

Nevisense (EIS) — Unproven in implied coverage context.

SSO2 Therapy (TherOx DownStream System) — Unproven.

Uterus transplantation (UTx) — Unproven.

Radiofrequency and other vaginal energy–based therapies for SUI and vulvo-vaginal laxity (including CMRF/Viveve) — Unproven.

Transurethral/Transvaginal radiofrequency devices for female SUI and vulvo-vaginal laxity — Unproven.

Histotripsy for malignant liver and renal tumors — Unproven.

Therapeutic ultrafiltration (Aquapheresis/Aquadex) for fluid overload/acute decompensated heart failure — Unproven.

Three-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue (3D breast imaging) — Unproven.

Alfapump (automated low-flow ascites pump) — Unproven; evidence summary suggests investigational use.

Ablative laser treatment for wound healing — Unproven.

Intraoperative radiation therapy (IORT) — Unproven for many indications; see evidence summaries.

RFA for joint pain — Unproven for specified indications.

Bronchoscopy with balloon occlusion and occlusive substance (adults >=18) — Unproven.

Bronchoscopic treatment of bronchopleural or bronchoalveolar fistulas (members <18) — Unproven.

Implantable wireless PAP sensor (CardioMEMS/Cordella) — Unproven for listed indications.

CardioMEMS / Hemodynamic-guided PAP monitoring — evidence summary does not support broad coverage; Unproven.

Periurethral adjustable balloon continence devices (ProACT/ACT) — Unproven.

UroCuff penile cuff test — Unproven.

MRgFUS coverage statements in this part where listed as Unproven apply.

Noninvasive tests for bladder outlet obstruction (BOO) — evidence summary does not support routine coverage; Unproven.

Surgical treatment of sacral perineural (Tarlov) cysts — separate medically necessary criteria exist; other uses Unproven.

Genicular Nerve Block (GNB) — Not medically necessary / Unproven.

Iris prosthesis (CustomFlex Artificial Iris) insertion — Not medically necessary / Unproven.

MRI-guided focused ultrasound subthalamotomy/thalamotomy for PD/ET — Unproven for routine coverage.

MBDA (Vectra) test — Unproven for routine clinical use.

Therapeutic drug monitoring (TDM) for biologics in IBD — follow clinical guidance; outside indications Unproven.

Spirometry and pulmonary function testing in children under age three — Not routinely covered / Unproven.

Robotic lower body exoskeletons and RAGT — Unproven.

External tremor stimulators (Cala TAPS) — Unproven.

Female external urinary collection devices — Unproven.

3D cranial implants — Unproven.

MyoPro powered upper extremity orthosis — Unproven.

Hair analysis — Unproven.

Unlisted code descriptions: when used to report technologies above, the Unproven determination applies.

Not Covered / Experimental Technologies & Procedures

Coding (Grouped by Coverage Status)

Unproven / Experimental CPT and HCPCS codesmixedExperimental

0061U	Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis.
0075T	Transcatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; initial vessel.
0076T	Transcatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; each additional vessel (List separately in addition to code for primary procedure).
0100T	Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy.
0163U	Oncology (colorectal) screening, biochemical enzyme-linked immunosorbent assay (ELISA) of 3 plasma or serum proteins (TDGF-1/Cripto-1, CEA, ECM), with demographic data using a proprietary algorithm and reported as likelihood of CRC or advanced adenomas.
0174T	Computer-aided detection (CAD) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure).
0175T	Computer-aided detection (CAD) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation.
0208T	Pure tone audiometry (threshold), automated; air only.
0209T	Pure tone audiometry (threshold), automated; air and bone.
0210T	Speech audiometry threshold, automated.

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1/13

Unproven / Experimental Additional CPT codesCPTExperimental

0207T	Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral.
0394T	High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed.
0395T	High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed.
0208T	Pure tone audiometry (threshold), automated; air only.
0209T	Pure tone audiometry (threshold), automated; air and bone.
0210T	Speech audiometry threshold, automated.
0211T	Speech audiometry threshold, automated; with speech recognition.
0212T	Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated.
0330T	Tear film imaging, unilateral or bilateral, with interpretation and report.
0333T	Visual evoked potential, screening of visual acuity, automated, with report.

1–10 of 16

1/2

Unproven / Experimental HCPCS and Misc codesmixedExperimental

L8608	[Included in policy as Unproven].
L8701	[Included in policy as Unproven].
L8702	[Included in policy as Unproven].
P2031	[Included in policy as Unproven].
S2117	[Included in policy as Unproven].
C2624	[Included in policy as Unproven].
C1839	[Included in policy as Unproven].
E1399	[Included in policy as Unproven].
E0734	[Included in policy as Unproven].
E1399	[Included in policy as Unproven].

Unproven / Experimental Unlisted and Category codesmixedExperimental

81599	Unlisted multianalyte assay with algorithmic report (listed as Unproven in policy).
93998	Unlisted vascular diagnostic procedure (listed as Unproven).
90999	Unlisted dialysis procedure (listed as Unproven).
19105	Biopsy procedures (listed as Unproven where applicable).
53860	Genitourinary procedures (listed as Unproven where applicable).
53899	Unlisted genitourinary procedure (listed as Unproven).
19294	Radiation oncology codes (listed as Unproven where applicable).
77424	Radiation physics consult (listed as Unproven where applicable).
77425	Remote device (listed as Unproven where applicable).

Unproven / Experimental Surgery and Device CPT codesCPTExperimental

53451	Insertion or revision of penile prosthesis components (listed as Unproven where applicable).
53452	Insertion or revision of penile prosthesis components (listed as Unproven where applicable).
53453	Insertion or revision of penile prosthesis components (listed as Unproven where applicable).
53454	Insertion or revision of penile prosthesis components (listed as Unproven where applicable).
53860	Urethral procedures (listed as Unproven where applicable).
55899	Unlisted male genital procedure (listed as Unproven).
61715	Stereotactic procedures (listed as Unproven where applicable).
63268	Spinal procedures (listed as Unproven where applicable).
64454	Nerve block procedures (listed as Unproven where applicable).
66683	Obstetric procedures (listed as Unproven where applicable).

Not Covered / Cosmetic or Miscellaneous CodesmixedNot Covered

A4542	Syringe, replacement part (listed as Not Covered where applicable).
K1007	Feeding tube supplies (listed as Not Covered where applicable).
L8699	Prosthetic implant, unspecified (listed as Not Covered where applicable).
L2999	Prosthetic implant, unspecified (listed as Not Covered where applicable).
23929	Unlisted procedure code (listed as Not Covered where applicable).
27299	Unlisted lower extremity procedure (listed as Not Covered where applicable).
27599	Unlisted lower extremity procedure (listed as Not Covered where applicable).
37799	Unlisted vascular procedure (listed as Not Covered where applicable).

Provider Actions — Prior Authorization, Documentation & Denial Risks

Note