New Technology and Miscellaneous Services
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Defines BCBSRI coverage determinations and administrative expectations for CPT codes representing new and emerging technologies (primarily Category III codes) for Medicare Advantage and Commercial products; affects providers submitting claims and prior authorization requests to Blue Cross Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Determinations and Medical Necessity
Coverage categories and medical necessity
BCBSRI coverage categories and medical necessity principles for new and emerging technologies
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For Medicare Advantage plans, devices categorized by the U.S. Food and Drug Administration as Category A (Experimental) are considered not medically reasonable and necessary and therefore not covered. A Category A device is defined as one for which the "absolute risk" of the device type has not been established and initial questions of safety and effectiveness remain unresolved.
Procedures for which reliable evidence indicates that prevailing expert opinion requires additional studies or clinical trials to determine safety, efficacy, toxicity, or comparative effectiveness are considered not medically necessary. For Commercial products, this is expressed as "Not medically necessary" when evidence is insufficient, which aligns with the requirement that services be consistent with diagnosis, necessary per accepted professional standards (i.e., not experimental), and provided at an appropriate level of care.
Coding Grid and Category III Details
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Provider Responsibilities and Authorization Rules
Prior Authorization Rules and PCP Exemption
Prior authorization requirements vary by product. For services that require prior authorization, refer to the Related Policies identified in the Code and Coverage Grid in the Coding section of this policy for appropriate medical criteria.
- Effective 10/1/2025, for Fully-Funded Commercial Products only, prior authorization requests may not be required when the requesting physician is a BCBSRI-contracted Primary Care Provider (PCP). This PCP exemption applies to the following specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA.
- Prior authorization continues to be required for all other Commercial Products, including Self-Funded and Medicare Advantage Plans.
Step Therapy
No step therapy protocols are specified in this policy.
Coding and Coverage Grid
Providers should refer to the attached Coding grid for coverage designations of new and existing unproven technologies for both Medicare Advantage and Commercial Products.
- Coding grid lists coverage categories used by BCBSRI for Medicare Advantage: Covered; Not Covered (evidence insufficient); Preauthorization required; Not separately reimbursed; Use alternate procedure code.
- Coding grid lists coverage categories used by Commercial Products: Covered; Not Covered and a contract exclusion; Not medically necessary (evidence insufficient); Preauthorization recommended; Not separately reimbursed; Use alternate procedure code.
Denial Risk and Coverage Categories
Procedures may be classified as Not Covered when the evidence is insufficient to determine the effects of the technologies on health outcomes. For Commercial Products, denials may be issued under the categories 'Not Covered and a contract exclusion' or 'Not medically necessary' when applicable. These classifications can lead to claim denials, including for Medicare Advantage members when the Not Covered category applies.
- Medicare Advantage: 'Not Covered' indicates evidence is insufficient to support coverage and may result in denial.
- Commercial Products: procedures may be denied as 'Not Covered and a contract exclusion' or as 'Not medically necessary' due to insufficient evidence.
Background and Purpose
The majority of CPT codes addressed in this policy are Category III CPT® codes, which are temporary codes established for emerging technologies, services, and procedures to facilitate collection of utilization and outcomes data. Use of an available Category III code is required in place of an unlisted Category I code; such codes are subject to archival five years from initial publication unless modified.
Key Terms and Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.