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New Technology and Miscellaneous Services (Category III CPT® Codes)
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Defines BCBSRI coverage categories and prior authorization rules for CPT codes representing new and emerging technologies (primarily Category III codes) for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria for New and Emerging Technology Codes
Coverage categories for new and emerging technology codes
BCBSRI uses category-based coverage determinations for new and emerging procedure codes; benefits vary by product and contract.
Applies differently to Medicare Advantage and Commercial Products as described in policy.
Medical necessity definition
Medically necessary criteria
If prevailing expert opinion is that more studies or clinical trials are necessary to determine safety, efficacy, toxicity, or comparative efficacy, the treatment or procedure is considered not medically necessary.
Device investigational policy
Medicare Advantage device coverage stance
Applies to Medicare Advantage Plans.
Benefits for services described in this policy may vary by group or contract. Providers and staff should always consult the member’s governing benefit documents — the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement — to confirm whether a particular service is covered or excluded for that member.
A service is considered medically necessary only when it meets all of the following: it is consistent with the patient’s symptoms and diagnosis; it is necessary for and consistent with generally accepted professional medical standards of care (that is, not experimental); it is not primarily for the convenience of the patient or provider; and it is furnished at the most appropriate level of care to provide safe and effective treatment.
The policy defines a treatment or procedure as not medically necessary when reliable evidence demonstrates that prevailing expert opinion requires additional studies or clinical trials to determine safety, efficacy, toxicity, maximum tolerated dose, or comparative effectiveness. For Medicare Advantage plans, devices categorized by the FDA as Category A (Experimental) are considered not medically reasonable and necessary and are not covered; Category B devices may be covered if otherwise medically reasonable and all Medicare requirements are met.
Codes, Grids, and Archival Rules
| No codes listed |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required; PCP exemption for Fully‑Funded Commercials
Prior authorization is required for services when the Code and Coverage Grid in the Coding section indicates prior authorization is needed. Effective 10/1/2025, Fully-Funded Commercial Products may not require prior authorization when the requesting physician is a BCBSRI-contracted primary care provider in the listed specialties; prior authorization remains required for all other Commercial Products (including Self-Funded) and Medicare Advantage Plans.
- See the Coding section's Code and Coverage Grid for which services require prior authorization.
- Exemption (effective 10/1/2025) applies only to Fully-Funded Commercial Products and only when the requesting physician is a BCBSRI-contracted PCP in the listed specialties.
Follow Code & Coverage Grid and Related Policies for prior authorization
When prior authorization is required, providers must follow the Related Policies identified in the Code and Coverage Grid in the Coding section for the applicable medical criteria. For Fully‑Funded Commercial Products the policy confirms the PCP exemption applies as specified in the Coding/prior authorization guidance.
- Follow the Related Policies listed in the Code and Coverage Grid for documentation and medical necessity criteria.
- Confirm whether the requesting provider meets the BCBSRI-contracted PCP specialties list to determine if the Fully‑Funded Commercial exemption applies.
Documentation sources: Related Policies in the Coding grid
For services that require prior authorization, providers must refer to the Related Policies identified in the Code and Coverage Grid in the Coding section for the appropriate medical criteria; the Coding section (attached grid) indicates coverage and prior authorization expectations.
- Use the Coding section's attached grid to identify required Related Policies and medical criteria.
- Ensure documentation submitted with authorization requests aligns with the Related Policies referenced in the grid.
Denial risk if prior authorization not obtained; limited PCP exemption
Requests for services may be denied if prior authorization is required and not obtained. The Fully‑Funded Commercial PCP exemption (effective 10/1/2025) may reduce denials for those specific requests; prior authorization remains required for other Commercial Products and Medicare Advantage Plans.
- If prior authorization is indicated in the Code and Coverage Grid and was not obtained, the request may be denied.
- The PCP exemption applies only to Fully‑Funded Commercial Products when the requesting clinician is a BCBSRI‑contracted PCP in the specified specialties.
Background on Category III CPT® Codes
Category III CPT® codes are temporary codes established to report emerging technologies, services, and procedures primarily to support data collection on utilization and outcomes. Their presence in coding does not, by itself, indicate established clinical benefit or guarantee coverage.
Category III codes are intended to identify and monitor new or evolving services and may be archived after a period (commonly five years from initial publication unless extended). Where a Category III code exists for a service, it should be used in place of a Category I unlisted code to ensure accurate tracking and data collection.
Key Definitions
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