CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy New Technology and Miscellaneous Services

Defines BCBSRI coverage categories and policies for procedure codes representing new and emerging technologies (primarily CPT Category III codes) for Medicare Advantage and Commercial products, including preauthorization and reimbursement guidance and relationship to related policies and benefit booklets.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy New Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeClarified guidance; no specific code listings

Effective DateFeb 1, 2025

Next Review Date

Key ActionFor Medicare Advantage plans, preauthorization is required for designated covered procedures and providers must refer to the Coding Section and Related Policies for authorization requirements and medical criteria.

SourceLink

POLICY UPDATE CHANGES

Policy outlines coverage categories and preauthorization requirements for CPT Category III and other new/unproven technologies for Medicare Advantage and Commercial products.

Category IIIPrimary focus

Medicare vs CommercialPlan distinctions noted

Coverage Summary

Defines BCBSRI coverage categories and policies for procedure codes representing new and emerging technologies, with a primary emphasis on Category III CPT codes for Medicare Advantage and Commercial products.

Medical-Necessity Criteria

Medical Necessity Requirements

Items and services must meet the following to be considered medically necessary:

ALL of the following

Consistent with the symptoms or diagnosis of the illness or injury under treatment
Not furnished primarily for the convenience of the patient or the provider or supplier
Necessary and consistent with generally accepted professional medical standards of care (not experimental)
Furnished at the most appropriate level of care that can be provided safely and effectively to the patient

General Coverage Categories

BCBSRI coverage categories for procedure codes for new and existing unproven technology include the following:

ANY of the following

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

Commercial Products Coverage Categories

BCBSRI coverage categories for procedure codes for new and existing unproven technology include the following:

ANY of the following

Commercial - Not Covered and a contract exclusion: Not Covered and a contract exclusion
Commercial - Covered: Covered
Commercial - Not medically necessary (insufficient evidence): Not medically necessary as the evidence is insufficient to determine the effects of the technologies on health outcomes
Commercial - Preauthorization recommended: Preauthorization is recommended

Medicare Advantage - Investigational Device Categories

Medicare Advantage coverage stance by FDA device categorization:

ALL of the following

Category A (Experimental) devices are considered not medically reasonable and necessary and are therefore not covered
Category B (non-experimental / investigational) devices may be covered if considered medically reasonable and necessary and all other applicable Medicare coverage requirements are met

Coding

Category III CPT codes are temporary codes created for emerging technologies, services, and procedures to allow collection of specific data on clinical efficacy, utilization, and outcomes rather than using unlisted Category I codes.

These codes are intended primarily for data collection and identification of new procedures; their inclusion in Category III does not imply coverage, and Category III codes are typically archived five years after initial publication unless an extension is noted.

Alternate / Unlisted code guidanceCPT

No codes listed

Provider Actions

Prior Authorization

Preauthorization required for Medicare Advantage covered procedures

For Medicare Advantage plans, preauthorization is required for services that are designated as covered; refer to the Coding Section and Related Policies for authorization requirements and medical criteria.

See the Coding Section (Code and Coverage Grid) for authorization requirements and specific codes.
Refer to Related Policies for medical criteria and documentation requirements.

Prior Authorization

Preauthorization recommended for Commercial Products

For Commercial Products, preauthorization is recommended; refer to the Coding Section and Related Policies for authorization requirements and medical criteria.

See the Coding Section (Code and Coverage Grid) for authorization recommendations and specific codes.
Refer to Related Policies for medical criteria and documentation requirements.

Billing Rule

Category III code reporting requirement

If a Category III CPT code exists for a service, that Category III code must be reported instead of a Category I unlisted code. Services and procedures described by Category III codes which have been archived, without conversion to a Category I code, must be reported with a Category I unlisted code unless another cross-reference is established at the time of archiving.

If a Category III code exists, report the Category III code instead of a Category I unlisted code.
If a Category III code has been archived and not converted to a Category I code, report with a Category I unlisted code unless a different cross-reference is specified.

Documentation Required

Follow Related Policies for medical criteria

For services that require authorization, providers must refer to the Related Policies identified in the Code and Coverage Grid found in the Coding Section of this policy for appropriate medical criteria and documentation to support coverage.

Providers must consult the Related Policies listed in the Code and Coverage Grid for the specific medical criteria and documentation required to support authorization and coverage decisions.

Background

The majority of CPT codes included in this policy are Category III CPT codes, a set of temporary codes for emerging technologies, services, and procedures. Category III codes allow data collection for these services/procedures and must be reported instead of a Category I unlisted code when available.

The use of Category III codes enables identification of emerging technologies, services and procedures for clinical efficacy, utilization and outcomes. Inclusion in Category III does not constitute a finding for or against clinical efficacy, applicability to practice, payer coverage, or safety. Category III codes are archived five years from initial publication or extension unless modified; archived Category III codes must be reported with a Category I unlisted code unless another cross-reference is established.

Definitions

Category III CPT codesTemporary CPT codes for emerging technologies, services, and procedures used for data collection and identification of new procedures. Use instead of Category I unlisted codes when available; typically archived five years after initial publication unless extended.

Category A deviceDevice for which absolute risk has not been established; considered experimental and not covered for Medicare Advantage.

Category B deviceDevice for which incremental risk is the primary question and may be covered if considered medically reasonable and necessary and all other applicable Medicare coverage requirements are met.