Experimental, Investigational and/or Unproven Procedures/Services/ADM1001.032

This policy addresses coverage of procedures, services, and technologies deemed experimental, investigational, and/or unproven—examples include automated eye‑tracking concussion tests (e.g., EyeBOX), percutaneous deep venous arterialization (LimFlow) for no‑option chronic limb‑threatening ischemia, and other emerging therapies. Coverage is limited to interventions supported by sufficient evidence or FDA/nationally recognized authoritative sources and by the member's benefit plan; many listed uses (for example eye‑tracking for suspected concussion in patients aged 5–67 within one week and only as an adjunct to a standard neurological assessment) are excluded or restricted pending additional data.

"Aid in the diagnosis of concussion within one week of head injury in patients aged 5 through 67 years when used in conjunction with a standard neurological assessment."