New Technology and Miscellaneous Services (Category III CPT® and related codes)
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Defines coverage determinations for CPT codes representing new and emerging technologies (primarily Category III codes) for BCBSRI Medicare Advantage and Commercial products; affects providers submitting claims and seeking prior authorization for these services.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
General coverage criteria and device investigational stance
Covered when meeting BCBSRI coverage categories and medical necessity principles as specified below.
See Coding section for code-specific coverage and prior authorization requirements.
Benefits and requirements may vary by group/contract; check the applicable Benefit Booklet or Evidence of Coverage.
Services must be established as safe and effective to be considered medically necessary.
May result in classification as Not Covered/Not medically necessary per product.
Applies specifically to Medicare Advantage Plans and may affect coverage determinations and denials.
The policy treats devices categorized by the U.S. Food and Drug Administration as Category A (Experimental) as not medically reasonable and necessary and therefore not covered. Category A devices are those for which the absolute risk for the device type has not been established and initial questions of safety and effectiveness remain unresolved.
An item or service is considered not medically necessary when reliable evidence indicates that prevailing expert opinion requires additional studies or clinical trials to determine the procedure’s safety, efficacy, toxicity, maximum tolerated dose, or comparative effectiveness versus standard treatment. Medical necessity also requires that services be consistent with the patient’s symptoms/diagnosis, adhere to generally accepted professional standards of care, not be primarily for convenience, and be furnished at the appropriate level of care.
For device-specific determinations, FDA device categorizations guide coverage: Category A devices are treated as experimental and not covered, while Category B devices may be covered only if they are determined to be medically reasonable and necessary and meet all other applicable Medicare coverage requirements.
Code and Coverage Grid
| Category III CPT codes (various) | Temporary CPT codes for emerging technologies; see attached grid for specific codes and coverage statuses. |
Provider Requirements and Prior Authorization
Prior authorization required per Coding grid
Prior authorization is required or recommended for services identified in the Coding Section; see the attached Code and Coverage Grid for which CPT codes require prior authorization and associated medical criteria.
- Prior authorization requirements are specified in the Code and Coverage Grid in the Coding section.
- Follow Related Policies identified in the grid for appropriate medical criteria.
Verify member benefits and contract-specific rules
Benefits and required pathways (such as step therapy or coverage exclusions) can differ by group or contract. Providers must check the member’s applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine member-specific requirements.
- Benefits may vary between groups/contracts.
- Refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable “Health Care Services Not Covered.”
Reference the Code & Coverage Grid and related prior auth rules
Providers must refer to the Code and Coverage Grid in the Coding section and the Related Policies identified there for the applicable medical criteria and prior authorization rules. Note the 10/1/2025 exemption for Fully‑Funded Commercial Products when the requesting physician is a BCBSRI contracted PCP (see policy for included specialties).
- Use the Code and Coverage Grid in the Coding section to identify applicable codes and prior authorization links.
- For Fully‑Funded Commercial Products, PA may not be needed when the requesting physician is a BCBSRI contracted PCP effective 10/1/2025 (see chunk 2 for listed specialties).
Category A (experimental) devices are not covered — denial risk
Services using FDA Category A (Experimental) devices are considered not medically reasonable and necessary and are therefore not covered; claims or requests involving Category A devices are subject to denial.
- Category A devices are considered not medically reasonable and necessary and therefore not covered.
- Category A refers to devices for which absolute risk and initial safety/effectiveness questions have not been resolved.
Background
Category III CPT® codes are temporary codes for emerging technologies, services, and procedures used to collect data on clinical efficacy, utilization, and outcomes. When available, a Category III code should be used instead of an unlisted Category I code. Category III codes are generally archived after five years unless revised or converted to a Category I code.
Definitions and Code Concepts
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