DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

New Technology and Miscellaneous Services

Defines Blue Cross Blue Shield of Rhode Island coverage determinations and billing guidance for CPT codes representing new and emerging technologies (primarily Category III CPT codes) across Medicare Advantage and Commercial products, including prior authorization exemptions for certain PCP specialties for fully-funded commercial products starting 2025-10-01.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date08/01/2026

Next Review Date

Key ActionFor services that require prior authorization, follow the Related Policies identified in the Code and Coverage Grid in the Coding Section of this policy for appropriate medical criteria; prior authorization continues to be needed for all Commercial Products except the listed PCP specialties for Fully-Funded Commercial Products effective 2025-10-01.

POLICY UPDATE CHANGES

No material clinical/coverage changes

Category IIIPrimary code type

2025-10-01PCP PA exemption effective

Medicare & CommercialProducts covered

Coverage Summary

This policy defines Blue Cross & Blue Shield of Rhode Island (BCBSRI) coverage determinations and billing guidance for CPT codes that represent new and emerging technologies, with primary focus on Category III CPT codes and other temporary/new procedure codes. It applies across Medicare Advantage and Commercial products and outlines how BCBSRI classifies procedure codes for unproven or emerging technologies (for example, covered, not covered, not separately reimbursed, or requiring alternative coding).

Coverage Categories & Criteria

General Coverage Determinations for New and Emerging Technology Procedure Codes

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

ANY of the following

Covered
Not Covered as the evidence is insufficient to determine the effects of the technologies on health outcomes
Preauthorization is required
Not separately reimbursed
Use alternate procedure code

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ref': 'b1_0

title': 'General Coverage Determinations for New and Emerging Technology Procedure Codes

Commercial Products Coverage Categories

BCBSRI coverage categories for procedure codes for new and existing unproven technology for Commercial Products include:

ANY of the following

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

Prior Authorization Exemption for Fully-Funded Commercial Products (Effective 2025-10-01)

Prior authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider for Fully-Funded Commercial Products only (effective 10/1/2025).

ALL of the following

Product type: Fully-Funded Commercial Products
Requesting provider specialty is one of
- Internal Medicine
- Pediatric Medicine
- Family Practice
- Obstetrics and Gynecology

Medicare Advantage Device Coverage Considerations

Medicare Advantage plans classify devices by FDA category with coverage implications:

ANY of the following

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

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title': 'Medicare Advantage Device Coverage Considerations'

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required for applicable services

For services that require prior authorization, follow the Related Policies identified in the Code and Coverage Grid in the Coding Section of this policy for appropriate medical criteria; prior authorization continues to be needed for all Commercial Products except the listed PCP specialties for Fully-Funded Commercial Products effective 2025-10-01.

Related Policies in the Code and Coverage Grid
Exception: Prior authorization may not be needed for listed PCP specialties for Fully-Funded Commercial Products effective 2025-10-01

Documentation Required

Use Category III CPT code when available

If a Category III CPT code exists for a service/procedure it must be reported instead of a Category I unlisted code to allow data collection; use a Category I unlisted code only when a Category III code is not available or another cross-reference is established.

Category I unlisted codes may be used only when no Category III code exists or another cross-reference is established

Billing Rule

Benefits and reimbursement may vary by contract

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage/benefits; inclusion in Category III does not imply coverage.

Check the member's Evidence of Coverage/Subscriber Agreement for plan-specific benefits and reimbursement

Denial Risk

Category A devices excluded for Medicare Advantage

Category A (Experimental) FDA devices are considered not medically reasonable and necessary and are therefore not covered under Medicare Advantage plans.

This exclusion applies to Medicare Advantage products per policy

Background & Definitions

The policy is intended to identify coverage determinations for CPT codes representing new and emerging technologies, noting that the majority of codes addressed are Category III CPT codes, which are temporary codes established to allow data collection for emerging services and procedures.

The document emphasizes that inclusion as a Category III code is for data collection and does not constitute a determination of clinical efficacy, safety, or payer coverage; Category III codes are temporary (generally archived five years from initial publication unless extended) and must be used instead of Category I unlisted codes when available.

Term	Definition
Category III CPT codes
Temporary CPT codes for emerging technology, services and procedures intended to allow data collection; must be used instead of Category I unlisted codes when available. Category III codes are temporary and may be archived five years from initial publication unless extended.
Category A device (FDA)
Experimental device for which absolute risk has not been established; considered not medically reasonable and necessary and therefore not covered for Medicare Advantage.
Category B device (FDA)
Non-experimental/investigational device where incremental risk is the primary question; may be covered if medically reasonable and necessary and all other applicable Medicare coverage requirements are met.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date08/01/2026

Next Review Date

On This Page

OpenPayer

New Technology and Miscellaneous Services

Coverage Summary

Coverage Categories & Criteria

Provider Actions & Billing Rules

Coding Guidance

Background & Definitions

Revision History