DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

New Technology and Miscellaneous Services Coverage Criteria

Defines BCBSRI coverage categories and prior authorization expectations for CPT codes representing new, emerging, or unproven technologies for Commercial and Medicare Advantage products; affects providers submitting claims to BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 11, 2025

Next Review DateAug 20, 2025

Key ActionObtain preauthorization for Medicare Advantage and most Commercial product requests unless the requesting physician is a BCBSRI-contracted primary care provider in a listed specialty.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Category IIIPrimary code type discussed

Medicare Adv. & CommercialProducts covered

Preauth requiredAuthorization stance

Use Cat IIICoding guidance

Coverage and Medical Necessity Categories

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Categories

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

Medicare Advantage Plans: Covered; Preauthorization is required; Not Covered when the evidence is insufficient to determine the effects of the technologies on health outcomes; Not separately reimbursed; Use alternate procedure code

applies to Medicare Advantage Plans

Commercial Products: Covered; Not Covered and a contract exclusion; Not medically necessary when the evidence is insufficient to determine the effects of the technologies on health outcomes; Preauthorization is recommended; Not separately reimbursed; Use alternate procedure code

applies to Commercial Products

Medicare Category A (experimental) devices are considered not medically reasonable and necessary and therefore are not covered. Category A denotes devices for which the FDA has not established the device type’s overall safety and effectiveness; initial safety and effectiveness questions remain unresolved, so these devices are excluded from coverage under Medicare Advantage plans.

A service or procedure is considered not medically necessary when reliable evidence demonstrates that prevailing expert opinion requires additional studies or clinical trials to determine the intervention’s safety, efficacy, toxicity, maximum tolerated dose, or comparative effectiveness. When such uncertainty exists, the service is excluded from coverage until sufficient evidence establishes it as safe and effective.

Coding Guidance and Attachments

Category III / New Technology CodesCPT

Category III CPT codes (various)

Temporary codes for emerging technologies; report Category III when available instead of unlisted Category I codes.

Coding Grid Attachmentmixed

2025_New Technology and Miscellaneous_Services

Attached coding grid referenced for Medicare Advantage Plans and Commercial Products coverage.

Category III archival timeline — inv-06

Archival timeframeCategory III CPT codes are generally archived approximately 5 years from the date of initial publication unless an extension is specifically noted.

Reporting after archivalIf a Category III code is archived without conversion to a Category I code, the service must be reported using a Category I unlisted code or another established cross‑reference at the time of archiving.

Purpose of archival ruleArchival timing reflects the temporary nature of Category III codes intended to allow data collection for emerging technologies; semiannual code updates may affect archival status.

Provider Requirements, Authorization & Billing

Prior Authorization

Prior Authorization Required

Preauthorization is required for Medicare Advantage and generally for Commercial (including Self-Funded) products. Authorization requests may not be needed when the requesting clinician is a BCBSRI-contracted Primary Care Provider in one of the following specialties: Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, Nurse Practitioner (NP) / Primary Care Provider (PCP), or Physician Assistant (PA). For services that require authorization, refer to related policies and the coding/coverage grid for applicable medical criteria.

BCBSRI-contracted PCP specialties exempt from prior auth: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics & Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA
Prior authorization required for Medicare Advantage and for Commercial products except when exemption above applies
For authorization requirements and medical criteria, see the Coding Section and Related Policies

Note

Benefit Verification

Benefits and coverage may vary by group contract. Always verify member benefits and any applicable "Health Care Services Not Covered" in the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement prior to scheduling or providing services.

Benefit verification required — consult member’s Benefit Booklet / Evidence of Coverage / Subscriber Agreement
Coverage differences may affect eligibility and reimbursement

Billing Rule

Coding Grid / Code-Specific Guidance

See the 2025 coding and coverage grid for code-specific guidance to support authorization and billing decisions. The grid identifies coverage categories used by BCBSRI (e.g., Covered, Not Covered/Contract Exclusion, Not Medically Necessary/Insufficient Evidence, Preauthorization Recommended, Not Separately Reimbursed) and lists the applicable CPT/HCPCS and other procedure codes.

Refer to: 2025_New Technology and Miscellaneous_Services coding grid
Grid contains code-level coverage status and guidance for Medicare Advantage and Commercial products
Use alternate procedure codes where indicated; some services are not separately reimbursed

Denial Risk

Denial Triggers / Coverage Exclusions

Services that are experimental, investigational, or not medically reasonable/necessary (for example Medicare Category A devices or technologies with insufficient evidence) are not covered and may be denied. Claims for services that fall into BCBSRI’s "Not Covered" categories or that are explicitly excluded by the member’s contract will be subject to denial.

Denial triggers include: experimental/investigational technologies; Medicare Category A devices; services judged not medically necessary due to insufficient evidence
Contract exclusions listed in the member’s Benefit Booklet/Evidence of Coverage may also trigger denials

Key Definitions

Category III CPT — inv-12

DefinitionCategory III CPT codes are temporary codes for emerging technologies, services, and procedures to permit data collection on clinical efficacy, utilization, and outcomes.

Reporting requirementWhen a Category III code is available, it must be reported instead of a Category I unlisted code.

Code lifecycleCategory III codes may be archived (typically ~5 years after initial publication) and may or may not convert to Category I codes.

Data collection purposeCategory III codes enable identification of emerging technologies for physicians, insurers, researchers, and policy experts to evaluate safety and effectiveness.

Medicare device categories — inv-13

Category A (Experimental)Devices classified by the FDA as Category A are considered experimental (absolute risk not established) and are not medically reasonable and necessary — therefore not covered.

Category B (Non-experimental/investigational)Category B devices may be covered if considered medically reasonable and necessary and all other applicable Medicare coverage requirements are met.

Risk distinctionCategory A refers to device types where initial safety and effectiveness questions remain unresolved; Category B indicates incremental risk is the primary question or prior approvals/clearances exist for the device type.

OpenPayer

New Technology and Miscellaneous Services Coverage Criteria

Coverage and Medical Necessity Categories

Coding Guidance and Attachments

Provider Requirements, Authorization & Billing

Background and Rationale

Key Definitions