CurrentAspirus ArisePolicy CP-AMCR24-003A

Category III (Temporary) CPT Codes Coverage

Governs coverage stance for Category III (temporary/T) CPT codes for Aspirus Arise health plans, indicating when these emerging technology codes are considered not covered and who this affects (providers submitting claims for Aspirus members).

Policy Summary

PayerAspirus Arise

PolicyCategory III (Temporary) CPT Codes Coverage

Policy CodePolicy CP-AMCR24-003A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit accurate and compliant claims; Category III CPT services will be denied unless specific coverage guidance (e.g., NCD, LCD, coverage article, or fee schedule) exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance for Category III codes

No PAPrior authorization policy

2025-01-01Policy effective date

Semi-annuallyAMA update frequency

Coverage Criteria

Not Covered / Not Medically Necessary Criteria

Category III CPT codes are considered not covered by Aspirus unless specific coverage guidance exists:

Default Not Covered Conditions: All Category III CPT codes are treated as not proven effective and are not covered by Aspirus unless there is specific coverage guidance (for example, an NCD, LCD, coverage article, or fee schedule) that addresses the specific Category III code.

Based on policy statement that Aspirus does not cover Category III codes absent specific guidance.

Reasons a service may be considered not medically necessary or denied: Any of the following may justify a not medically necessary or denial determination: experimental or investigational; not generally accepted in the medical community as safe and effective for the setting and condition; furnished at an inappropriate level, duration, or frequency; not medically necessary in the particular case; not proven safe and effective in peer-reviewed scientific literature; furnished in an inappropriate setting for the patient’s needs; not furnished in accordance with accepted standards of medical practice; or furnished primarily for convenience.

Enumerated examples from policy of conditions that justify denial or NMN determinations.

Policy Summary

PayerAspirus Arise

PolicyCategory III (Temporary) CPT Codes Coverage

Policy CodePolicy CP-AMCR24-003A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit accurate and compliant claims; Category III CPT services will be denied unless specific coverage guidance (e.g., NCD, LCD, coverage article, or fee schedule) exists.

SourceLink

On This Page

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Provider Actions / Billing Guidance

Prior Authorization

Prior authorization is not required for Category III CPT codes under this policy.

Denial Risk

Denial Risk for Category III Codes

Claims for services billed with Category III CPT codes will be denied unless there is specific guidance for coverage such as a Medicare NCD, an applicable LCD, or a published coverage article. Aspirus considers Category III codes experimental or not proven effective unless explicit coverage guidance exists.

Category III CPT codes are not covered unless an NCD, LCD, coverage article, or fee schedule specifically addresses coverage.

Documentation Required

Provider Documentation Responsibilities

Providers are responsible for submission of accurate and compliant claims and should refer to the member's Aspirus plan documents (Evidence of Coverage/Member Handbook/Member Contract) for specific coverage details. Items and services must be documented and supported in the medical record to demonstrate medical necessity.

Follow plan documents for product-specific coverage.
Document items and services to support medical necessity.

Note

Informational

Aspirus does not cover Category III codes unless there is specific coverage guidance (NCD, LCD, coverage article, or fee schedule). Category III services are considered experimental, not generally accepted as safe and effective for the billed setting or condition, or not medically necessary unless proven otherwise. Claims submitted for such codes without appropriate coverage guidance will be denied.

Category III CPT codes — treated as not covered absent specific CMS or Aspirus guidance.
Refer to CMS/CGS for Medicare NCDs, LCDs, and coverage articles.

Definitions

Category III CPT / Temporary (T) codes

DefinitionCategory III CPT (Temporary/T) codes are temporary codes for emerging technology, services, and procedures intended to track usage; they are generally considered experimental, investigational, or unproven.

DurationTemporary codes can remain in Category III for up to five years.

Possible outcomesCategory III codes may be reassigned to Category I when criteria are met (e.g., FDA approval, evidence of widespread provider adoption, and proof of effectiveness) or eliminated if providers do not use them.

Purpose of data collectionUsage data collected from Category III coding may be used to support FDA approval and to substantiate widespread adoption.

Updates and publicationThe AMA releases new or revised Category III codes semi‑annually; deletions are published annually with the full set of Category III codes.

OpenPayer

Category III (Temporary) CPT Codes Coverage

Coverage Criteria

Coding / Code Lists

Provider Actions / Billing Guidance

Definitions

Background

Not Covered Statement