Products and Services Considered Experimental and Investigational These are products and services that have not met our evidence-based standards of safety and effectiveness; thus, these products and services are not covered benefits. Service Code Service Code Type Service Code Description 20560 CPT Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 CPT Needle insertion(s) without injection(s); 3 or more muscles Bone marrow aspiration for bone grafting, spine surgery only, 20939 CPT through separate skin or fascial incision (List separately in addition to code for primary procedure) Percutaneous intradiscal electrothermal annuloplasty, unilateral 22526 CPT or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral 22527 CPT or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image 22867 CPT guidance when performed, with open decompression, lumbar; single level Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image 22868 CPT guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or 22869 CPT fusion, including image guidance when performed, lumbar; single level Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or 22870 CPT fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) Arthrodesis, sacroiliac joint, percutaneous or minimally invasive 27279 CPT (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Arthrodesis, open, sacroiliac joint, including obtaining bone graft, 27280 CPT including instrumentation, when performed Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring 28890 CPT anesthesia other than local, including ultrasound guidance, involving the plantar fascia Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved 32994 CPT by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, 33274 CPT fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. 1 of 58 SS-PHS-DOC-001D (08/26/21) Products and Services Considered Experimental and Investigational These are products and services that have not met our evidence-based standards of safety and effectiveness; thus, these products and services are not covered benefits. Service Code Service Code Type Service Code Description Transcatheter removal of permanent leadless pacemaker, right 33275 CPT ventricular Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart 33289 CPT catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the 34717 CPT internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (List separately in addition to code for primary procedure) Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre- procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision 34718 CPT and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer), unilateral Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a 34841 CPT fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated 34842 CPT radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. 2 of 58 SS-PHS-DOC-001D (08/26/21) Products and Services Considered Experimental and Investigational These are products and services that have not met our evidence-based standards of safety and effectiveness; thus, these products and services are not covered benefits. Service Code Service Code Type Service Code Description Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated 34843 CPT radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated 34844 CPT radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or 34845 CPT modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or 34846 CPT modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or 34847 CPT modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. 3 of 58 SS-PHS-DOC-001D (08/26/21) Products and Services Considered Experimental and Investigational These are products and services that have not met our evidence-based standards of safety and effectiveness; thus, these products and services are not covered