CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

New Technology and Miscellaneous Services (Category III and related CPT codes)

Defines BCBSRI coverage determinations for CPT codes representing new and emerging technologies (Category III and related unproven procedures) for Medicare Advantage and Commercial products; applies to providers submitting claims to Blue Cross Blue Shield Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services (Category III and related CPT codes)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionFor services requiring authorization, refer to the Related Policies in the Code and Coverage Grid in the Coding section for applicable medical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage & Commercialproduct lines

Category IIIcode focus

Preauthorization notedauthorization

Referencedrelated policies

Coverage determinations and medical necessity

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage category assignments

BCBSRI assigns one of several coverage categories to procedure codes for new and unproven technologies; benefits may vary by contract.

Medicare Advantage coverage categories: Covered; Preauthorization is required; Not Covered as the evidence is insufficient to determine the effects of the technologies on health outcomes; Not separately reimbursed; Use alternate procedure code

Each code will be categorized into one of these stances per Medicare Advantage plan

Commercial Products coverage categories: Covered; Not Covered and a contract exclusion; Not medically necessary as the evidence is insufficient to determine the effects of the technologies on health outcomes; Preauthorization is recommended; Not separately reimbursed; Use alternate procedure code

Each code will be categorized into one of these stances per commercial contract/benefit

Benefits for services described in this policy vary by contract. Providers should consult the member’s specific plan documents — including the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement — to determine whether a given procedure is covered or listed as a contract exclusion under "Health Care Services Not Covered."

A treatment or procedure is considered not medically necessary when reliable evidence and prevailing expert opinion indicate that additional studies or clinical trials are required to determine its efficacy, safety, dosing, maximum tolerated dose, or how it compares with established standard treatments or diagnostic methods.

Code guidance and archival rules

Category III / Emerging Technology CodesCPT

Category III CPT codes

Temporary CPT codes for emerging technologies; must be reported when available instead of Category I unlisted codes

Category III archival timeframe

Archival timeframeCategory III codes are generally archived five years from the date of initial publication unless an extension is noted

Post-archival reportingServices described by archived Category III codes that are not converted to Category I must be reported using Category I unlisted codes or another established cross-reference at the time of archiving

Code availabilityNew or revised Category III codes are released semi‑annually via the AMA CPT website

Purpose of archival policyArchival allows reassessment of whether the emerging service/procedure has sufficient evidence and adoption to warrant Category I coding

Prior authorization, billing and provider responsibilities

Prior Authorization

Prior Authorization Required

Preauthorization is required for services as specified in the Coding and Coverage Grid. Providers must consult the Related Policies referenced in the Coding section to determine which services need prior authorization and to review the applicable medical criteria. Lack of preauthorization may result in claim denial or referral to the related policy criteria for coverage determination.

Preauthorization requirement is tied to the Coding Grid and Related Policies.
Failure to obtain required preauthorization may lead to denial or retrospective review.

Note

Benefit Verification and Member Notification

Providers must verify member benefits and eligibility prior to scheduling services. Benefit determinations are member- and contract-specific; the member's subscriber agreement, certificate, or employer agreement governs coverage. For member-specific benefit questions or to confirm prior authorization requirements, contact the BCBSRI provider call center.

Verify member benefits and eligibility before providing services.
Inform and obtain written agreement from member if providing non-covered services at member's expense.

Billing Rule

Billing, Coding and Product-Specific Requirements

Providers are responsible for following billing and coding guidance in the Coding section. When a service is not separately reimbursed or an alternate procedure code is required, use the guidance in the Code and Coverage Grid. Preauthorization recommendations or requirements listed by product line (Medicare Advantage vs Commercial) must be followed according to the member's plan.

For Medicare Advantage: many items are covered but preauthorization is required; some items are not separately reimbursed or not covered.
For Commercial Products: review coverage categories (covered, not covered, preauthorization recommended, not separately reimbursed).

Note

Background on Category III CPT codes

Category III CPT codes are temporary codes established to identify emerging technologies, services, and procedures and to enable collection of data on clinical efficacy, utilization, and outcomes. When a Category III code exists it must be reported instead of a Category I unlisted code. In general, a Category III code will be archived five years from initial publication unless extended; if a code is archived without conversion to a Category I code the service should be reported using a Category I unlisted code or other specified cross-reference. Items and services described by Category III codes are not automatically supported or denied by their inclusion; they must still meet the requirements for medical necessity (safe, effective, consistent with the diagnosis, not primarily for convenience, and consistent with accepted standards of care).

Key definitions

Category III — definition

DefinitionTemporary CPT codes for emerging technologies, services and procedures used to collect data on clinical efficacy and utilization

Reporting requirementIf a Category III code is available it must be reported instead of a Category I unlisted code

Data purposeAllows physicians, insurers, researchers and policy experts to identify and collect utilization and outcomes data for emerging services/procedures

Does not imply endorsementInclusion as Category III does not constitute support or lack of support regarding clinical efficacy, applicability to practice, payer coverage, or safety

Medicare investigational device categories

Category A (Experimental)Devices for which absolute risk has not been established; considered not medically reasonable and necessary and are not covered

Category B (Non-experimental/investigational)Devices for which initial safety/effectiveness questions have been resolved and incremental risk is primary; may be covered if medically reasonable/necessary and all Medicare requirements are met

Coverage implicationCategory A = not covered; Category B = may be covered when Medicare coverage criteria are satisfied