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2013 Investigational List

The list below includes services considered investigational. However, it does not include transplants or drugs than may be considered investigation. Please refer transplant inquiries to case management at (800) 627-1187 Ext 8872, option 1 or (208) 331-8872, option 1. Please direct questions about potentiallfy investigational drugs to Pharmacy Management at (800) 274-4018 Ext 6666 or (208) 387-6666.

This investigational list is not all-inclusive. We make additions and deletions as new issues arise or the investigational status of a service changes.

Investigational services are often so new that they do not have a procedure code assigned to them yet.  Therefore, not all of the services listed have CPT or HCPCS codes.

We approve or deny services and supplies clearly related to an investigational service based on approveal of the service itself. This includes related hospitalization, outpatient services, office calls, diagnostic lab and x-ray, supplies and medications.

For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 

Blue Cross of Idaho Medical Policy for determination of medical necessity versus investigational care are only applicable to Blue Cross of Idaho members.  For our Host members, the determination of medical necessity versus investigational care is determined by the Home Plan Medical Policy,  as related to its  administration of the Member’s benefits and coverage. 

These policies may not apply to all lines of business such as Federal Employee Program, Medicare Advantage and certain self-insured groups.

Last updated 4/30/2013

Blue Cross of Idaho Investigational Services and Supplies Procedure/Diagnoses
(Anodyne) Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 93784, 93786, 93788, 93790
Dynamic Posturography  92548
Transcutaneous Electrical Nerve Stimulator (TENS)  
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome  
H-Wave Electrical Stimulation  
Bronchial Thermoplasty 31660, 31661, 0276T, 0277T
Endobronchial Valves 31647, 31648, 31649, 31651
Orthopedic Applications of Stem Cell Therapy f  
Biofeedback as a Treatment of Urinary Incontinence in Adults  90875, 90876
Neurofeedback  90875, 90876
Biofeedback as a Treatment of Headache  90875, 90876
Biofeedback as a Treatment of Chronic Pain  90875, 90876
Biofeedback for Miscellaneous Indications  90875, 90876
Biofeedback as a Treatment of Fecal Incontinence or Constipation  90875, 90876
Pelvic Floor Stimulation as a Treatment of Urinary Incontinencef E0740, 0029T
Threshold Electrical Stimulation as a Treatment of Motor Disorders  
Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions E0221, A4639
Transtyanic Micropressure Applications as a Treatment of Meniere`s Disease A4638, E2120
Intratympanic Injection of a Pharmacologic Agent for the Treatment of Meniere`s Disease or Sudden Hearing Loss 386.00-386.04, 370.52, 388.2
Interferential Stimulation   
Electrical/Electromagnetic Stimulation for the Treatment of Arthritis E0762 
Thoracic-Lumbo-Sacral Orthosis with Pneumatics E0830
Sympathetic Therapy for the Treatment of Pain  
Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology)   
Gait Analysis  
Hyperbaric Oxygen Pressurization (HBO2) A4575
Rhinomanometry and Acoustic Rhinometry 92512
Intraepidermal Nerve Fiber Density Testing   
Topographic Brain Mapping S8040
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome 0207T, 0330T
Intravenous or Subcutaneous Histamine Therapy 90774 when used with histamine
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy 477.0-477.9
Serial Endpoint Testing for the Diagnosis and treatment of Allergic Disorders 95027
Sensory Stimulation for Coma Patients S9056
Injectable Clostridial Collagenase for Fibroproliferative Disorders   
Prolotherapy M0076
Biofeedback as a Treatment of Urinary Incontinence in Adults E0746
Neurofeedback E0746
Biofeedback as a Treatment of Headache E0746
Biofeedback as a Treatment of Chronic Pain E0746
Home Spirometry 94014, 94015, 94016, E0487, S8096, S8190(deleted code)
Cutaneous Electrogastrography (EGG) 91132, 91133
Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain S3900
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis   
Percutaneous Vertebroplasty and Sacroplasty  0200T, 0201T
Axial Lumbosacral Interbody Fusion  
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 43257, 43201
Quantitative Sensory Testing 0106T, 0107T, 0108T, 0109T, 0110T, G0255
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 28890, 0019T, 0101T, 0102T
Noncontact Radiant Heat Bandage for the Treatment of Wounds E0231, E0232, A6000
Chronic Intermittent Intravenous Insulin Therapy (CIIIT) 250 range
Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems) 0046T, 0047T
Vacuum Therapy as a Treatment for Female Sexual Dysfunction 302.7, 625.5, 625.8, 625.9, 627.4, 627.9, 629.8, 629.9
Inpatient Intestinal Rehabilitation Therapy  
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric Disorders 0160T, 0161T
Fiberoptic Analysis of Colorectal Polyps 211.3
Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer   
Biofeedback for Miscellaneous Indications E0746
Percutaneous Transluminal Angioplasty of Intracranial Atherosclerotic Stenoses With or Without Stenting 61630, 61635
Breast Duct Endoscopy   
Low-Level Laser Therapy as a Treatment of Carpal Tunnel Syndrome 354; S8948
Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds E0769, G0281, G0282, G0295, G0329, E0761
Non-Contact Ultrasound Treatment for Wounds 0183T
Transanal Radiofrequency Treatment of Fecal Incontinence C9716
Transvaginal Radiofrequency Bladder Neck Suspension for Urinary Stress Incontinence 625.6
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 0193T
Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and Other Respiratory Disorders 0064T, 0140T (deleted 12/31/09), 83987 (new 1/01/10), 95012
Extracorporeal Shock Wave Therapy in the Treatment of Peyronie’s Disease 607.89
Electrical Impedance Scanning of the Breast  
Biofeedback as a Treatment of Fecal Incontinence E0746
Aerosolized Antibiotics as a Treatment of Chronic Sinusitis 473.0-473.9
Monitoring of Regional Cerebral Blood Flow Using an Imlanted Cerebral Thermal Perfusion Probe 0077T
Breath Test for Heart Transplant Rejection Detection 0085T
Laser Treatment for Acne 706.1
Temporary Prostatic Stent 53855 
Non-Pharmacologic Treatment of Rosacea 695.3
Insulin Potentiation Therapy 250 code range
Actigraphy 95803
Intratympanic Injections of a Pharmacologic Agent for the Treatment of Meniere’s Disease or Sudden Hearing Loss 386.00-386.04, 370.52, 388.2
Percutaneous Treatment of Fracture Non-Unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM) 733.8
Anti-CCP Testing for Rheumatoid Arthirits 714.0-714.9, 83698
Rhinophototherapy 0168T
Signal-Averaged Electrocardiography 93278
Enhanced External Counterpulsation (EECP) for Treatment of Chronic Stable Angina or CHF 92971, G0166
Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry  
Noninvasive Measurements of Cardiac Hemodynamics in the Outpatient Setting 93701, 0104T, 0105T
T-Wave Alternans 93025
Wearable Cardioverter-Defibrillators for the Prevention of Sudden Cardiac Death   
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis 0126T
End Diastolic Pneumatic Coression Boot as a Treatment of Peripheral Vascular Disease or Lyhedema 92971, G0166
Autologous Cell Therapy for the Treatment of Damaged Myocardium 427.31
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as Treatment for Atrial Fibrillation 427.31
Correlated Audioelectric Cardiography 0068T, 0069T, 0070T
Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting 0086T
In Vitro Chemoresistance and Chemosensitivity Assays   
Serum Tumor Markers for Breast and Gastrointestinal Malignancies 86300, 86301
Tumor Vaccine for Melanoma  
Microwave Thermotherapy for Primary Breast Cancer  
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin 197.6
Intensity Modulated Radiation Therapy (IMRT) 171.0-174.9, 162.2-162.9
Cervicography V72.3
Salivary Estriol as Risk Predictor for Preterm Labor 644
Measurement of Small Low-density Lipoprotein (LDL) Particles and Concentration of LDL Particles in Cardiac Risk Assessment and Management 83700, 83701, 83704
Genetic Testing for Familial Alzheimer's Disease 331; S3852, S3855
Genetic Testing for Helicobacter Pylori Treatment  
Biochemical Markers of Alzheimer's Disease 83912
Collagen Cross Links as Markers of Bone Turnover 82523
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 555
Pharmacogenomic and Metabolite Markers for Patients with Inflammatory Bowel Disease Treated with Azathioprine (6-MP) 555.0-555.9, 556
Apolipoprotein B in the Risk Assessment and Management of Cardiovascular Disease 250, 272, 410-414, 440, 443, V12.5, V17.3-V17.4
Lipoprotein(a) Enzyme Immunoassay in the Management of Cardiovascular Disease

83695

250, 272, 410-414, 440, 443, V12.5, V17.3-V17.4

High-Sensitivity C-Reactive Protein  
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease 83090
High-density Lipoprotein Subclass Testing in the Diagnosis and Management of Cardiovascular Disease 250, 272, 410-414, 440, 443, V12.5, V17.3-V17.4
Apolipoprotein E Genotype or Phenotype in the Management of Cardiovascular Disease 250, 272, 410-414, 440, 443, V12.5, V17.3-V17.4
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis  
Transcatheter Pulmonary Valve Implantation  
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening  
Measurement of Serum Intermediate Density Lipoproteins (Remnant-like Particles) 0026T
Measurement of Lipoprotein-associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk 83698
Gene-Based Tests for Screening, Detection and/or Managment of Prostate Cancer  
Analysis of Proteomic Patterns in Serum to Identify Cancer  
Detection of Circulating Tumor Cells in the Management of Patients with Cancer 174; S3711
Cytochrome p450 Genotyping  
Serum Holo-Transcobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status 0103T
Measurement of Long-Chain Omega-3 Fatty Acids in Red Blood Cell Membranes as a Cardiac Risk Factor 0111T
Combination of Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Patients with Chronic Liver Disease  
Leukocyte Histamine Release Test 86343
Genetic Testing for the Congenital Long QT Syndrome 426.82, 746.89
Genetic Testing for Mutations Associated with Malignant Melanoma Susceptibility  
Genetic Testing for Familial Alzheimer's Disease 81405, 81406
Genetic Testing for Familial Cutaneous Malignant Melanoma 81404
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)  
Biomarker Genes for Detection of Lymph Node Metastases in Breast Cancer  
Serum Biomarker Human Epididymis Protein 4 (HE4)  86305
Genetic Testing for Initial Warfarin Dose  
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid S1030, S1031
Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification 304
Speculoscopy 0031T, 0032T
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrheaf 617, 625.30 
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 625.5
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids 218.0-218.9
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss  
Assisted Reproductive Technologies  
Off-Label Uses of Trastuzumab  
Off-Label Uses of Infliximab  
Alpha-Fetoprotein-L3 for Detection of Hepatocellular (Liver) Cancer 82107
Intravenous Lidocaine for the Management of Chronic Pain  
Computed Tomography to Detect Coronary Artery Calcification  
Thermography 93760, 93762
Ultrasound for the Evaluation of Paranasal Sinuses 473
Videofluoroscopic Evaluation of Velopharyngeal Dysfunction 70370, 70371
Scintimammography S8080
Magnetoencephalography/Magnetic Source Imaging S8035, 95965, 95966, 95967
Sacroiliac Joint Arthrography 27096, 73542, G0259, G0260
Magnetic Resonance Spectroscopy 76390
Positional Magnetic Resonance Imaging   
CT Scanning for Lung Cancer Screening 0174T, 0175T
Virtual Colonoscopy/CT Colonography as a Screening Test for Colorectal Cancer 0066T, 0067T
Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition 0028T
Whole Body Computed Tomography Scan as a Screening Test V76.0-V76.9, V81.0-V81.6
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) 77082
Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast 0159T (add-on code for 76093 or 76094)
Dynamic Spinal Visualization  
CT (Computed Tomography) Perfusion Imaging 0042T
Angelchik™ Anti-Reflux Prosthesis 530.11, 530.81, 553.3
Balloon Dilatation of Prostate  
Disposable Arthroscopy  
Embryonic Mesencephalic Transplantation for the Treatment of Parkinson's Disease 332
Meniscal Allograft Transplantation  
Percutaneous Discectomy 62287
Cerebellar Stimulation/Pacemaker  
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)  
Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae  
Adrenal-to-Brain Transplantation S2103
Surgery for Morbid Obesity  
Autologous Chondrocyte Transplantation  
Dynamic Cardiomyoplasty  
Minimally Invasive Coronary Artery Bypass Graft Surgery S2205, S2206, S2207, S2208, S2209
Partial Left Ventriculectomy  
Extracranial Carotid Angioplasty/Stenting 37215, 37216, 0075T, 0076T
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET) and Percutaneous Intradiscal Radiofrequency Annuloplasty

722 code range

0062T, 0063T, 22526, 22527

Gastric Electrical Stimulation 43647, 43648, 43881, 43882, 64590, 64595, 95980, 95981, 95982, 0155T, 0156T, 0157T, 0158T, 0162T
Cryosurgical Ablation of Primary or Metastatic Liver Tumors 47371, 47381
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 28446
Cryoablation of Clinically Localized Prostate Cancer for subtotal prostatectomy only
Total Hip Resurfacing 715 code range, 733.42 (non-metal-on-Metal) 
Sural Nerve Graft in Association with Radical Prostatectomy 185
Thermal Capsulorrhaphy as a Treatment of Joint Instability 718.21, 718.31, 959.2, S2300
Semi-Implantable Middle Ear Hearing Aid for Moderate to Severe Sensorineural Hearing Loss S2230, V5095
Artificial Intervertebral Disc: Lumbar Spine  22857, 22862, 22865, 0163T, 0164T, 0165T
Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee 715 code range
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 50250, 50593, 0135T
Decompression of Intervertebral Discs Using Laser (Laser Discectomy) or Radiofrequency Energy (DISC Nucleoplasty™) 62287, S2348
Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure 20985, 20986, 20987
Minimally Invasive Hip and Knee Arthroplasty  
Vasectomy Using a Polymeric Clip Facility charges would reflect cost of the polymeric clip used during the 55450 procedure
Minimally Invasive Surgery for Snoring, Obstructive Sleep Apnea Syndrome/Upper Airway Resistance Syndrome

327.23, 780.51, 780.53, 780.57

 

Surgical Ventricular Restoration 33548
Subtalar Arthroereisis S2117
Balloon Sinuplasty for Treatment of Chronic Sinusitis S2344
Posterior Tibial Nerve Stimulation for Voiding Dysfunction  
Interspinous Distraction Devices (Spacers) 0171T, 0172T, C1821
Artificial Intervertebral Disc: Cervical Spine  
MRI-Guided High-Intensity Ultrasound Ablation of Uterine Fibroids and Other Tumors 0071T, 0072T
Wireless Pressure Sensors in Endovascular Aneurysm Repair 34806, 93982
Electromagnetic Navigation Bronchoscopy  31626, 31627
Transanal Endoscopic Microsurgery  
Adoptive Immunotherapy S2107
Intraoperative Radiation Therapy S8049
Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies 155.0-155.2, 197.7
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma 204.10-204.11
Lysis of Epidural Adhesions 0027T, 62263, 62264
High-dose Chemotherapy and Hematopoietic Stem-cell Support for Epithelial Ovarian Cancer 183
High-Dose Chemotherapy and Hematopoietic Stem-Cell Support for Miscellaneous Solid Tumors in Adults 162.0-162.9, 171.0-171.9
High-Dose Chemotherapy and Autologous Stem-Cell Support for Autoimmune Diseases, Including Multiple Sclerosis 340, 710.0, 710.1, 714.0-714.9
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Breast Cancer 174
High-Dose Chemotherapy and Autologous Stem-Cell Support for Malignant Astrocytomas and Gliomas 191.0-191.9
High-Dose Rate Temporary Prostate Brachytherapy C1717 dx: 185
Treatment of Tinnitus 388.3
Spinal Manipulation Under Anesthesia 00640, 22505
Implantation of Intrastromal Corneal Ring Segments 0099T
Interleukin-2 as a Treatment of HIV Infection  
Selective Internal Radiation Therapy for Primary and Metastatic Tumors of the Liver 155.0,153-153.9
Daily Hemodialysis in the Home 99512, S9335, E1500, E1510, E1520, E1530, E1540, E1550, E1560, E1570, E1575, E1580, E1590, E1600, E1610, E1615, E1620, E1625, E1635, E1636, E1637, E1639, E1699
Functional Neuromuscular Stimulation to Provide Ambulation E0764
Vertebral Axial Decompression S9090
Cognitive Rehabilitation  
Hippotherapy S8940
Sensory Integration Therapy 97533
Keratoprosthesis 65770, C1818, L8609
Orthoptic Training for the Treatment of Learning Disabilities  
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization 0016T
Ocular Photoscreening in the Primary Care Physician’s Office as a Screening Tool to Detect Amblyogenic Factors  
Impantation of Intrastromal Corneal Ring Segments 371.60-371.62 
Subconjunctival Retinal Prosthesis 0100T
Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension 0124T
Transciliary Fistulization for the Treatment of Glaucoma 0123T 
Epiretinal Radiation Therapy for Age-Related Macular Degeneration 0190T
Emerging Surgical Treatments for Glaucoma 0191T, 0192T
Electrocardiographic Body Surface Mapping 0178T, 0179T, 0180T
Anterior Eye Segment Optical Imaging 0187T
Optical Coherence Tomography for Imaging of Coronary Arteries 0291T, 0292T
Endovascualr Grafts for Abdominal Aortic Aneurysms 0078T, 0079T, 0080T, 0081T
Use of Common Genetic Variants to Predict Risk of Non-familial Breast Cancer   
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer   
Intracellular Micronutrient Analysis    
DNA-Based Testing for Adolescent Idiopathic Scoliosis    
Array Comparative Genomic hybridzation (aCGH) for the Genetic Evaluation of Patients with Developmental Delay/Mental Retardation or Autism Spectrum Disorder    
Aversion Therapy for Chemical Dependency    
Baroreflex Stimulation Devices  0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T
NOTCH 3 Genotyping for Diagnosis of CADASIL  81406
Viscocanalostomy and Canaloplasty    
Auricular Electrostimulation   
Total Artificial Hearts and Implantable Ventricular Assist Devices 33990, 33991, 33992, 33993

To also check our cosmetic list, please click here.

To also check our prior authorization list, click here.