CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

New Technology and Miscellaneous Services

Policy defines coverage determinations and billing categories for CPT codes that represent new and emerging technologies (primarily CPT Category III) for BCBSRI Medicare Advantage and Commercial products, including prior authorization rules and an attached coding grid. It also specifies an exemption from prior authorization for certain fully-funded commercial PCPs effective 2025-10-01.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeClarified prior-auth exemption for Fully-Funded Commercial PCPs

Effective DateJun 1, 2026

Next Review Date

Key ActionFor services requiring prior authorization, follow the Related Policies in the Code and Coverage Grid; prior authorization continues to be required for Self-Funded Commercial and Medicare Advantage plans.

SourceLink

POLICY UPDATE CHANGES

Effective 10/01/2025 exemption from prior authorization for Fully-Funded Commercial Products when requesting clinician is a BCBSRI contracted PCP in specified specialties.

Category IIIPrimary code focus

2025-10-01Prior-auth exemption effective

2026-06-01Policy effective

Coverage Summary

This policy defines coverage determinations for CPT codes that represent new and emerging technologies, with primary emphasis on Category III CPT codes. It applies to BCBSRI Medicare Advantage and Commercial products and includes prior authorization rules and an attached Coding and Coverage Grid for specific code-level guidance.

Publication history: policy content has been published in multiple Provider Updates between 2022 and 2026 and the publisher reserves the right to revise the policy at any time.

Context and attachments: see the Coding and Coverage Grid (attached) and related policies for detailed code-level criteria and prior authorization procedures; an exemption from prior authorization for certain Fully-Funded Commercial PCPs is documented separately (effective 10/01/2025).

Policy dates and quick facts

Effective Date06|01|2026

Last Review04|01|2026

Next Review

Coverage Stancemixed

Primary code focusCategory III emphasized

Prior-auth exemption effective date10/01/2025 (Fully-Funded Commercial PCPs only)

Medical-Necessity & Coverage Criteria

General Coverage Categories for Procedure Codes

BCBSRI coverage categories include the following (Medicare Advantage and Commercial as specified):

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

Medical Necessity Principles

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

Medical Necessity Requirements

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

Prior Authorization Exemption for Fully-Funded Commercial PCPs

Effective 10/1/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be needed when the requesting clinician is a BCBSRI contracted Primary Care Provider in the following specialties:

Prior Authorization Exemption Criteria

Requesting clinician is a BCBSRI contracted Primary Care Provider
Primary Care Specialties
- Internal Medicine
- Pediatric Medicine
- Family Practice

Medicare Advantage Investigational Device Coverage

Coverage depends on FDA device categorization:

Medicare Advantage Device Coverage

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

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required per code/grid

Follow the Related Policies identified in the Code and Coverage Grid (attached) for services that require prior authorization. Note that prior authorization requirements continue to apply for Self‑Funded Commercial and Medicare Advantage plans.

Affected plan types: Self‑Funded Commercial; Medicare Advantage; other Commercial Products per Code and Coverage Grid (attached)

Prior Authorization

Prior authorization exemption for certain Fully-Funded Commercial PCPs

Effective 10/01/2025, prior authorization requests may not be needed for Fully‑Funded Commercial Products when the requesting clinician is a BCBSRI contracted Primary Care Provider in the listed specialties. This exemption applies only to Fully‑Funded Commercial Products; prior authorization continues to be required for Self‑Funded Commercial and Medicare Advantage plans.

Applicable specialties: Internal Medicine
Pediatric Medicine
Family Practice
Obstetrics and Gynecology
Doctor of Osteopathic Medicine (DO)
NP (Nurse Practitioner)/PCP (Primary Care Physician or Provider)
PA (Physician Assistant)
Plan scope: Fully‑Funded Commercial Products only; exemption does NOT apply to Self‑Funded Commercial or Medicare Advantage

Documentation Required

Use Category III codes when available

When a Category III CPT code exists for a service or procedure, report that Category III code rather than a Category I unlisted code to enable collection of data on emerging technologies and procedures.

Billing Rule

Archived Category III handling

If a Category III CPT code has been archived without conversion to a Category I code and no specific cross‑reference was established at archiving, report the service using the appropriate Category I unlisted code.

Documentation Required

Member benefit verification

Verify member benefits and eligibility, and review the applicable "Health Care Services Not Covered" provisions in the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before billing.

Coding Guidance & Attachments

The policy’s coding focus is primarily on Category III CPT codes as temporary codes for emerging technologies used to enable data collection; see the attached Coding and Coverage Grid for Medicare Advantage and Commercial coverage determinations and the related policies cited in the policy for prior authorization and medical necessity requirements.

Category III CPT codes (general guidance)CPT

No codes listed

Coding and Coverage Grid (attached)mixed

No codes listed

Background & Definitions

Background and scope: the majority of codes in this policy are Category III CPT codes, which are temporary codes intended to collect data on emerging technologies, services and procedures and must be reported when available instead of Category I unlisted codes. For Medicare Advantage, coverage decisions also depend on FDA device categorization: Category A devices (experimental) are considered not medically reasonable and necessary and are not covered, while Category B devices may be covered if medically reasonable and necessary and all other Medicare requirements are met. The policy also reiterates general medical necessity principles that items and services must meet to be considered medically necessary.

Term	Definition
Category III CPT codes
Temporary CPT codes for emerging technology, services and procedures used to collect data; should be used instead of Category I unlisted codes when available.
Category A device (FDA)
An experimental device for which absolute risk has not been established and safety/effectiveness questions remain; considered not medically reasonable and necessary and not covered under Medicare Advantage.
Category B device (FDA)
A non-experimental/investigational device where incremental risk is the primary question; may be covered if medically reasonable and necessary and all other Medicare coverage requirements are met.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeClarified prior-auth exemption for Fully-Funded Commercial PCPs

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

New Technology and Miscellaneous Services

Coverage Summary

Medical-Necessity & Coverage Criteria

Provider Actions & Billing Rules

Coding Guidance & Attachments

Background & Definitions

Revision History