New Technology and CPT Codes for Medicare Advantage and Commercial Products
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Defines BCBSRI coverage categories and practices for Current Procedural Terminology (CPT) codes representing new and emerging technologies, and explains prior authorization applicability for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Categories & Device Considerations
Coverage Categories and Device Considerations
BCBSRI coverage categories and general device-related guidance; benefits may vary by contract.
Coverage categories
- Covered
- Not Covered (evidence insufficient to determine effects on health outcomes)
- Not Covered and a contract exclusion
- Not medically necessary (evidence insufficient; more studies required)
- Preauthorization required or recommended
- Not separately reimbursed / Use alternate procedure code
FDA device categories
- Category A (Experimental): considered not medically reasonable and necessary and are not covered. Category A refers to device types for which absolute risk has not been established and initial questions of safety and effectiveness remain.
- Category B (Non-experimental / investigational): may be covered if considered medically reasonable and necessary and all other applicable Medicare coverage requirements are met. Category B refers to device types for which incremental risk is the primary question and safety/effectiveness of the device type has been sufficiently addressed.
Category III CPT and Archival Timeframe
| Category III CPT codes | Temporary codes for emerging technology, services and procedures; must be used instead of Category I unlisted codes when available. |
Prior Authorization Requirements & PCP Exemption
Prior authorization required; PCP exemption for Fully‑Funded Commercial Products (effective 10/01/2025)
For services that require prior authorization, refer to the related policies listed in the Code and Coverage Grid in the Coding Section of this policy for appropriate medical criteria. Effective 10/1/2025, Fully‑Funded Commercial Products may be exempt from prior authorization when the requesting physician is a BCBSRI‑contracted primary care provider (see list of included specialties). Prior authorization remains required for all other Commercial Products, including Self‑Funded and Medicare Advantage Plans.
- Exemption applies only to Fully‑Funded Commercial Products and only when the requesting physician is a BCBSRI‑contracted PCP.
- Included PCP specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA.
- Prior authorization still required for Self‑Funded Commercial Products and Medicare Advantage Plans.
Key Definitions
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