Near-Infrared (NIR) Spectroscopy (CPB 0796, reviewed 2025-11-19)

Immediately effective as of November 19, 2025: Billing team must update claim submission and adjudication system to flag and deny all claims for CPT codes 0640T, 0859T, 0860T when billed for any NIR spectroscopy indication listed in policy (cerebral perfusion monitoring, wound assessment, peripheral artery disease screening, flap viability assessment, and all psychiatric/neurological diagnostic uses). For related codes 92978, 92979 (intravascular ultrasound during coronary intervention): deny or require prior authorization when billed with diagnosis codes indicating NIR intravascular ultrasound use for lipid-rich plaque detection. Update billing software logic to cross-reference diagnosis codes (sepsis A40.0-A41.9, mental/behavioral disorders F01.50-F99, stroke sequelae I69.xx, diabetic foot disease E08.621-E13.621, peripheral artery disease I70.0-I79.8, and others listed) against procedure codes 0640T, 0859T, 0860T and initiate automatic claim denials or prior authorization requests. Providers must be notified that these procedures are not covered for experimental/investigational indications; update provider communication and encounter templates to reflect non-coverage. Establish denial reason code linking to CPB 0796 to ensure transparent claim explanations to providers and patients. Failure to implement will result in processing claims for non-covered services and potential recovery of incorrectly paid claims.