DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

DRAFT Medical Coverage Policy New Technology and Miscellaneous Services

Defines BCBSRI coverage determinations and administrative rules for CPT codes representing new and emerging technologies (primarily Category III CPT codes) across Medicare Advantage and Commercial products, including preauthorization rules and distinctions for fully-funded commercial PCPs.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDRAFT Medical Coverage Policy New Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeClarified authorization exemption for select PCPs

Effective DateJan 1, 2026

Next Review Date

Key ActionFor Fully-Funded Commercial Products, note that authorization requests may be waived effective 2025-10-01 when requested by specified BCBSRI contracted primary care provider specialties; continue preauthorization for other products as indicated.

SourceLink

POLICY UPDATE CHANGES

Effective 2025-10-01, for Fully-Funded Commercial Products only, authorization requests may not be needed when the requesting physician is a BCBSRI contracted primary care provider.

Category III focusedPrimary code type

Varies by contractBenefit variability

Preauth requiredMedicare Advantage preauth

Preauth recommendedCommercial preauth

Coverage Summary

Defines BCBSRI coverage determinations and administrative rules for CPT codes representing new and emerging technologies (primarily Category III CPT codes) across Medicare Advantage and Commercial products, including preauthorization rules and distinctions for Fully-Funded Commercial primary care providers. Effective date: 01/01/2026. Policy last reviewed: 09/17/2025. Coverage stance: mixed.

Key policy attributes

Primary code typeCategory III focused

Benefit variabilityVaries by contract

Medicare Advantage preauthPreauth required (MA)

Commercial preauthPreauth recommended (Commercial)

Effective date2026-01-01

Last review2025-09-17

Coverage Categories and Criteria

Medicare Advantage Plans Coverage Categories

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

ANY of the following

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

Coding

Alternate / Unlisted codes guidanceCPT

No codes listed

Provider Actions & Administrative Rules

Prior Authorization

Preauthorization requirement for Medicare Advantage

Preauthorization is required for covered services under Medicare Advantage Plans.

Prior Authorization

Prior authorization recommended for Commercial Products

Preauthorization is recommended for Commercial Products; for Fully-Funded Commercial Products authorization may be waived when requested by specified contracted PCP specialties effective 2025-10-01.

Waiver effective date: 2025-10-01
Applies only to Fully-Funded Commercial Products (not Self-Funded or Medicare Advantage)
Applies to listed BCBSRI contracted primary care provider specialties (see criteria tree / credentialed specialties list)

Background & Definitions

This policy addresses coverage determinations for new and emerging technologies, primarily Category III CPT codes, which are temporary codes for emerging services and procedures used to allow collection of data. The inclusion of a Category III code does not imply coverage. Items and services must be established as safe and effective, consistent with generally accepted professional medical standards, and meet medical necessity criteria to be covered.

Definitions

Policy subjectNew Technology and Miscellaneous Services (Category III CPT codes)

ScopeMedicare Advantage and Commercial products; rules vary by contract

Coverage stancemixed

Revision History

2025-10-01clarified

List of included PCP specialties provided; authorization requests may not be needed for specified contracted PCPs for Fully-Funded Commercial Products effective 2025-10-01.

2026-01-01effectiveLatest

Policy effective date.

2025-09-17last_review

Policy last reviewed.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDRAFT Medical Coverage Policy New Technology and Miscellaneous Services

Policy CodePolicy N/A

Change TypeClarified authorization exemption for select PCPs

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

Commercial Products Coverage Categories

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

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
Use alternate procedure code

Authorization exemption for Fully-Funded Commercial Products

Effective 2025-10-01, authorization requests may not be needed when the requesting physician is a BCBSRI Contracted Primary Care Provider for Fully-Funded Commercial Products only:

ALL of the following

Requesting physician must be a BCBSRI Contracted Primary Care Provider
Credentialed specialties included
- Internal Medicine
- Pediatric Medicine
- Family Practice
- Obstetrics and Gynecology
- Doctor of Osteopathic Medicine
- NP / PCP: NP (Nurse Practitioner) / PCP (Primary Care Physician Or Provider)
- PA (Physician Assistant)
Prior authorization continues to be needed for all other Commercial Products, including Self Funded and Medicare Advantage Plans

Medicare Advantage Investigational Devices

Coverage distinctions by FDA device category:

ALL of the following

Category A devices
- Category A devices are considered not medically reasonable and necessary and are therefore not covered
Category B devices
- Category B devices may be covered if considered medically reasonable and necessary and all other applicable Medicare coverage requirements are met

Documentation Required

Report Category III CPT when available

If a Category III CPT code is available it must be reported instead of a Category I unlisted code to allow collection of data on emerging services/procedures.

Billing Rule

Not separately reimbursed / use alternate code

Some new or unproven technology procedure codes may be not separately reimbursed and an alternate procedure code should be used as indicated.

Denial Risk

Not medically necessary determinations

Services considered experimental/investigational or lacking sufficient evidence may be determined not medically necessary and denied per benefit documents.