CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

New Technology and Miscellaneous Services (Category III and related procedure codes)

Defines BCBSRI coverage categories and authorization expectations for CPT codes representing new and emerging technologies for Medicare Advantage and Commercial products; intended for providers submitting claims and seeking prior authorization.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNew Technology and Miscellaneous Services (Category III and related procedure codes)

Policy CodePolicy N/A

Change TypeTechnical/administrative — no material clinical changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain preauthorization for Medicare Advantage members; for Commercial members, preauthorization is recommended and benefits may vary by contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage & CommercialProducts covered

MA required / Commercial recommendedAuthorization expectation

5 yearsArchival timeframe

Category III CPT focusCoding focus

Coverage Criteria

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Coverage categories

BCBSRI coverage categories for procedure codes for new and existing unproven technology are listed separately for Medicare Advantage and Commercial products.

Medicare Advantage coverage categories: 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

Commercial Products coverage categories: 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

Category A (experimental) devices are considered not medically reasonable and necessary and are therefore not covered under Medicare Advantage. Benefit coverage may vary by contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific lists of services and any contract exclusions that apply.

A treatment or procedure is considered not medically necessary when reliable evidence demonstrates that prevailing expert opinion is that additional studies or clinical trials are needed to determine the intervention's efficacy, safety, toxicity, or comparative effectiveness. Services and procedures must be established as safe and effective and consistent with generally accepted professional medical standards to be considered medically necessary; otherwise they are categorized as not medically necessary.

Coding

Coding grid (Category III and related codes)mixed

No codes listed

Category III archival timeframe

Archival timeframeCategory III CPT codes are archived five years from the date of initial publication unless an extension or modification is specified.

Post-archival reportingServices described by archived Category III codes that were not converted to Category I must be reported using a Category I unlisted code unless a specific cross-reference is provided at archiving.

Purpose of temporary codesCategory III codes are temporary codes for emerging technologies, services, and procedures intended to allow data collection on clinical efficacy, utilization, and outcomes.

Provider Actions & Authorization

Prior Authorization

Preauthorization required for MA; recommended for Commercial

Medicare Advantage: preauthorization is required. For Commercial products, preauthorization is recommended; for services that require authorization follow Related Policies identified in the Code and Coverage Grid in the Coding section.

Follow Related Policies in the Code and Coverage Grid for services that require authorization.

Step Therapy

Confirm benefit and contract-specific requirements

Benefits and required prior authorization may vary by contract; providers must refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific benefit, coverage, and step requirements.

Check the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for group/contract-specific coverage rules.

Billing Rule

Use Category III CPT codes when available

When a Category III CPT code exists for a service or procedure, that Category III code must be reported instead of a Category I unlisted code to allow data collection; see the Coding section and Related Policies for the coding grid and any specific documentation requirements.

Report Category III CPT codes rather than Category I unlisted codes when available to permit data collection.
Refer to the Coding grid and Related Policies for code-specific guidance and documentation requirements.

Denial Risk

Denial risk if MA preauthorization not obtained

For Medicare Advantage plans, failure to obtain required preauthorization may result in denial or noncoverage for services represented by new or unproven technology codes.

Obtain preauthorization for applicable Medicare Advantage services to avoid claim denials or noncoverage.

Background

Category III CPT codes are temporary codes for emerging technologies, services, and procedures created to permit data collection on clinical efficacy, utilization, and outcomes. When a Category III code exists it must be reported instead of a Category I unlisted code to facilitate identification and tracking. Category III codes are subject to archival five years from the date of initial publication unless their archival date is extended or they are converted to Category I codes; services described by archived Category III codes revert to reporting with Category I unlisted codes unless another cross-reference is provided.

Definitions

Category III CPT codes — temporary codes, archived after five years if not converted

Nature of Category III codesCategory III CPT codes are temporary codes for emerging technologies, services and procedures to allow collection of data for clinical efficacy, utilization and outcomes.

Requirement to use Category III when availableIf a Category III code is available, it must be reported instead of a Category I unlisted code to enable data collection.

Archival ruleCategory III codes will be archived five years from the date of initial publication unless the archival date is modified.

Reporting after archivalServices described by archived Category III codes that have not been converted to Category I codes must be reported with a Category I unlisted code unless another cross-reference is established at archiving.

Medicare device categories (A/B) — Category A not covered; Category B may be covered if reasonable and necessary

Category A devicesCategory A (experimental) devices are considered not medically reasonable and necessary and are therefore not covered.

Definition of Category ACategory A (Experimental) device: a device for which absolute risks of the device type have not been established and initial safety and effectiveness questions remain unresolved.

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

Definition of Category BCategory B device: a device for which the incremental risk is the primary question and initial safety/effectiveness questions have been resolved (or similar device types have FDA approval/clearance).