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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyPriority Health Medicare CPT III Coverage | OpenPa…
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    ModifiedPriority Health MedicarePolicy 91636

    Category III Current Procedural Terminology (CPT) Codes

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    This policy governs Priority Health Medicare coverage of temporary CPT Category III (“T”) codes used for emerging technologies, services, procedures, and service paradigms. Unless another Priority Health or utilization-management delegate policy or guideline provides medical-necessity criteria, services represented by these codes are considered experimental, investigational, or unproven.

    Policy Summary
    PayerPriority Health Medicare
    PolicyCategory III Current Procedural Terminology (CPT) Codes
    Policy CodePolicy N/A
    Change TypeModified
    Effective Date06/01/2026
    Next Review DateN/A
    Key ActionCheck the Priority Health Provider Manual and Prism Authorization Criteria Lookup for applicable prior-authorization requirements.
    SourceLink
    POLICY UPDATE CHANGES

    The coding table lists only active Category III CPT 'T' codes that do not appear in another Priority Health medical policy, are considered not separately payable, or are managed by a Priority Health utilization-management delegate.

    The medical-necessity criteria were clarified.

    Titles of relevant American Medical Association guidance were moved to the guidelines and position-statements section.

    58Document pages
    33Active Category III codes listed
    11Codes identified as medically necessary
    2Codes not separately payable
    Category IIITemporary CPT code category

    Medical Necessity and Coverage Determination

    Category III Medical-Necessity Determination

    Coverage or management follows an applicable policy when that policy addresses medical necessity; otherwise the Category III service is considered experimental, investigational, or unproven.

    Applicable alternate coverage policy: A separate Priority Health medical policy or Utilization Management delegate medical policy or guideline specifically addresses medical necessity for the particular Category III code.

    Refer to the applicable policy or guideline for its criteria; that policy may still classify the service as experimental, investigational, unproven, or not medically necessary.

    Default Category III position: No other Priority Health medical policy or Utilization Management delegate medical policy or guideline specifically addresses medical necessity for the particular Category III code.

    The item, service, or procedure represented by the code is considered experimental, investigational, or unproven under this policy.

    CMS and Mandate Precedence

    Apply applicable federal or state mandates and current CMS coverage requirements.

    Policy Summary
    PayerPriority Health Medicare
    PolicyCategory III Current Procedural Terminology (CPT) Codes
    Policy CodePolicy N/A
    Change TypeModified
    Effective Date06/01/2026
    Next Review DateN/A
    Key ActionCheck the Priority Health Provider Manual and Prism Authorization Criteria Lookup for applicable prior-authorization requirements.
    SourceLink
    On This Page
    Medical Necessity and Coverage DeterminationCategory III CPT Code TablesAuthorization, Submission, and Coverage ControlsPurpose and ContextKey Terms
    Medicare and mandate precedence: Any applicable federal or state mandates take precedence over this medical coverage policy, and Medicare coverage must be evaluated using the most current CMS National Coverage Determination, Local Coverage Determination, Local Coverage Article, CMS manual, or transmittal applicable to the plan's MAC jurisdiction.

    Consult the current CMS Medicare Coverage Database and CMS sources because CMS coverage information may be updated after this policy's review date.

    Medical-Necessity Review

    When prior authorization is required, the provider must demonstrate medical necessity.

    Prior authorization medical-necessity review: The request must demonstrate that the drug, service, or procedure is medically necessary.

    This criterion applies when prior authorization is required.

    Investigational Treatment Exception

    Individual consideration may allow coverage for investigational but promising care.

    Exception review for experimental, investigational, or unproven treatment: The request requires prior plan approval and must involve either a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

    Coverage determinations are made by a Priority Health medical director or clinical pharmacist.

    Inclusion of a Category III CPT service or procedure in the CPT code set does not establish clinical efficacy, safety, applicability to clinical practice, or payer coverage. Category III descriptions do not establish that a service or procedure is safe, effective, or applicable to medical practice.

    Unless another Priority Health medical policy or Utilization Management delegate policy or guideline specifically addresses medical necessity for the particular Category III code, the item, service, or procedure is considered experimental, investigational, or unproven. Such treatment is excluded from coverage unless an applicable exception is reviewed and approved.

    CPT code 0518T, removal of the battery component of the pulse generator for a wireless cardiac stimulator for left ventricular pacing, is marked not medically necessary.

    Category III CPT Code Tables

    Active CPT Category III codesCPTExperimental
    0054TComputer-assisted musculoskeletal surgical navigational orthopedic procedure with fluoroscopic image guidance.
    0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure with CT/MRI image guidance.
    0075TTranscatheter placement of extracranial vertebral artery stent(s); initial vessel.
    0076TTranscatheter placement of extracranial vertebral artery stent(s); each additional vessel.
    0098TRevision including replacement of total disc arthroplasty; each additional cervical interspace.
    0106TQuantitative sensory testing using touch pressure stimuli.
    0107TQuantitative sensory testing using vibration stimuli.
    0108TQuantitative sensory testing using cooling stimuli.
    0109TQuantitative sensory testing using heat-pain stimuli.
    0164TRemoval of total disc arthroplasty, anterior approach, lumbar; each additional interspace.
    1–10 of 33
    1/4
    Category III Current Procedural Terminology (CPT) CodesCPT
    0219TPlacement of posterior intrafacet implant; cervical.
    0220TPlacement of posterior intrafacet implant; thoracic.
    0221TPlacement of posterior intrafacet implant; lumbar.
    0222TPlacement of posterior intrafacet implant; each additional vertebral segment.
    0235TTransluminal peripheral atherectomy; visceral artery.
    0236TTransluminal peripheral atherectomy; abdominal aorta.
    0237TTransluminal peripheral atherectomy; brachiocephalic trunk and branches.
    0238TTransluminal peripheral atherectomy; iliac artery.
    0274TPercutaneous laminotomy or laminectomy; cervical.
    0331TMyocardial sympathetic innervation imaging.
    1–10 of 113
    1/12
    Category III Current Procedural Terminology (CPT) CodesCPT
    0608TRemote pulmonary fluid monitoring; analysis and reports.
    0609TMagnetic resonance spectroscopy for discogenic pain; biomarker acquisition.
    0610TMagnetic resonance spectroscopy; biomarker transmission.
    0611TMagnetic resonance spectroscopy; algorithmic postprocessing.
    0612TMagnetic resonance spectroscopy; interpretation and report.
    0613TInteratrial septal shunt device implantation.
    0615TAutomated binocular eye-movement analysis for concussion.
    0632TTranscatheter ultrasound ablation of pulmonary-artery nerves.
    0633TUnilateral breast CT with 3D rendering, without contrast.
    0634TUnilateral breast CT with 3D rendering, with contrast.
    1–10 of 83
    1/9
    Category III Current Procedural Terminology (CPT) CodesCPT
    0794TAlgorithm ranking pharmaco-oncologic treatment options.
    0795TDual-chamber leadless pacemaker, complete system insertion.
    0796TDual-chamber leadless pacemaker, right atrial component insertion.
    0797TDual-chamber leadless pacemaker, right ventricular component insertion.
    0798TDual-chamber leadless pacemaker, complete system removal.
    0799TDual-chamber leadless pacemaker, right atrial component removal.
    0800TDual-chamber leadless pacemaker, right ventricular component removal.
    0801TDual-chamber leadless pacemaker, dual-chamber system replacement.
    0802TDual-chamber leadless pacemaker, right atrial component replacement.
    0803TDual-chamber leadless pacemaker, right ventricular component replacement.
    1–10 of 101
    1/11
    Category III CPT CodesCPT
    0890TMRI-guided theta-burst stimulation; initial treatment day.
    0891TMRI-guided theta-burst stimulation; subsequent treatment day.
    0892TMRI-guided theta-burst stimulation; motor-threshold redetermination day.
    0893TNoninvasive assessment of blood oxygenation and gas exchange efficiency.
    0897TAugmentative computational cardiac arrhythmia analysis.
    0898TNoninvasive prostate cancer estimation map.
    0899TAlgorithmic myocardial blood-flow quantitation from contrast CMR.
    0900TAssistive algorithmic myocardial blood-flow estimate from contrast CMR.
    0901TPlacement of bone-marrow sampling port.
    0902TAlgorithmically derived QTc interval from mobile ECG.
    1–10 of 41
    1/5
    Medically Necessary Category III CPT CodesCPTCovered
    0937TExternal electrocardiographic recording for greater than 15 days up to 30 days; complete service.
    0938TExternal electrocardiographic recording for greater than 15 days up to 30 days; recording.
    0939TExternal electrocardiographic recording for greater than 15 days up to 30 days; scanning analysis and report.
    0940TExternal electrocardiographic recording for greater than 15 days up to 30 days; review and interpretation.
    Additional Category III CPT CodesCPT
    0935TCystourethroscopy with renal pelvic sympathetic denervation.
    0936TPhotobiomodulation therapy of retina.
    0944T3D contour simulation of target liver lesion(s).
    0945TIntraoperative computer-aided fluorescence assessment of tumor tissue.
    0946TOrthopedic implant movement analysis using paired CT.
    0947TMRgFUS stereotactic blood-brain barrier disruption.
    0948TRemote interrogation of cardiac contractility modulation system, up to 90 days.
    0949TRemote data acquisition for cardiac contractility modulation system, up to 90 days.
    0950TTransrectal HIFU ablation of benign prostate tissue.
    0951TInitial placement of totally implantable active middle-ear hearing implant.
    1–10 of 50
    1/5
    Category III CPT codesCPT
    0987TIntracranial cerebral-vessel OCT; additional vessel.
    0988TOpen insertion or replacement of integrated bladder neurostimulation system.
    0993TNoninvasive cardiac-risk assessment from perivascular fat without concurrent cardiac CT.
    0994TNoninvasive cardiac-risk assessment from perivascular fat with concurrent cardiac CT.
    0995TEndovascular delivery of aortic wall stabilization drug therapy.
    0996TInsertion and scleral fixation of capsular bag prosthesis with intraocular lens.
    0997TPrecuneus magnetic stimulation treatment planning.
    0998TPrecuneus magnetic stimulation personalized treatment delivery.
    0999TAutologous muscle cell therapy; harvesting of muscle progenitor cells.
    1000TAutologous muscle cell therapy; administration into urethral sphincter.
    1–10 of 12
    1/2
    Category III CPT codesCPT
    1003TArthroplasty of first carpometacarpal joint with prosthetic.
    1004TElectronic analysis of implanted sub-scalp EEG system without programming.
    1005TElectronic analysis of implanted sub-scalp EEG system with programming; first 15 minutes.
    1006TElectronic analysis of implanted sub-scalp EEG system with programming; additional 15 minutes.
    1007TEEG review, analysis, interpretation, and report, up to 30 days.
    1008TRemote monitoring setup for implanted sub-scalp EEG system.
    1009TRemote monitoring review and analysis of implanted sub-scalp EEG events.
    1010TComputerized ophthalmic analysis of monocular eye movements.
    1012TMotorized ab interno trephination of sclera or trabecular meshwork.
    1013TLaparoscopic implantation or replacement of lower esophageal sphincter neurostimulator.
    1–10 of 17
    1/2
    Category III CPT codesCPT
    1030TDigital 3D model from patient-specific anatomy; initial 30 minutes.
    1031TDigital 3D model from patient-specific anatomy; additional 30 minutes.
    1032TDigital 3D model and simulation; initial 30 minutes.
    1033TDigital 3D model and simulation; additional 30 minutes.
    1034TDigital 3D model, simulation, and computational analyses; initial 90 minutes.
    1035TDigital 3D model, simulation, and computational analyses; additional 30 minutes.
    1036TNoninvasive hemodynamic assessment with pulmonary pressures and ejection fraction.
    1038TAutologous muscle cell injection into tongue.
    1039TConnectomic analysis of previously performed multimodal brain MRI.
    1040TFlexible bronchoscopy with bronchial cryotherapy.
    1–10 of 17
    1/2
    COMS therapy wound surface area
    Code0906T
    ServiceConcurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; first application
    Wound surface areaLess than or equal to 50 sq cm
    Digitized cytopathology extended study
    Code0835T
    ServiceDigitization of glass microscope slides for cytopathology, smears, any other source; extended study
    Study thresholdOver 5 slides and/or multiple stains
    Remote multi-day complex uroflowmetry device supply
    Code0812T
    ServiceRemote multi-day complex uroflowmetry device supply with automated report generation
    Supply durationUp to 10 days

    Authorization, Submission, and Coverage Controls

    Prior Authorization

    Check Prior Authorization Requirements

    Prior authorization may be required for certain drugs, devices, services, and procedures. Verify requirements in the Priority Health Provider Manual or through Prism’s Authorization Criteria Lookup before providing care.

    • Check EviCore, InterQual, or TurningPoint criteria when applicable.
    • When authorization is required, submit a request demonstrating medical necessity.
    Prior Authorization

    Obtain Individual-Consideration Approval

    Investigational but promising care may qualify for coverage through individual case review. Requests for individual consideration require prior plan approval, and coverage determinations are made by a Priority Health medical director or clinical pharmacist.

    • Do not proceed under an individual-consideration exception without prior plan approval.
    • Any exception review for experimental, investigational, or unproven treatment is subject to applicable conditions.

    Unsupported block type: documentation้

    Denial Risk

    No Applicable Medical-Necessity Policy

    If no separate Priority Health medical policy or Utilization Management delegate policy or guideline specifically addresses a Category III code, the item, service, or procedure is considered experimental, investigational, or unproven under this policy.

    • Check for an applicable Priority Health or UM delegate policy before submitting the request.
    • A separate policy or guideline may still classify the service as experimental, investigational, unproven, or not medically necessary.
    Billing Rule

    Verify Plan, Mandate, and CMS Controls

    Coverage is controlled by the member’s benefits, applicable federal or state mandates, CMS coverage determinations, and group-specific policy. Federal or state mandates take precedence over this policy.

    • For Medicare members, consult the current CMS National Coverage Determination, Local Coverage Determination, Local Coverage Article, and CMS manuals or transmittals.
    • Group-specific policy supersedes this policy when applicable.
    Denial Risk

    0518T Is Not Medically Necessary

    CPT Category III code 0518T—removal of the pulse generator for a wireless cardiac stimulator for left ventricular pacing, battery component only—is identified as not medically necessary.

    • Do not represent 0518T as medically necessary under this policy.
    • Review applicable plan terms and any other controlling coverage requirements.
    Denial Risk

    Experimental or Unproven Treatment

    Category III items, services, and procedures are generally considered experimental, investigational, or unproven when no applicable medical-necessity policy or guideline applies. Coverage may be excluded, but an exception may be reviewed for individual consideration when applicable conditions are met.

    • Individual consideration requires prior plan approval.
    • Exception review may apply when the condition is terminal or is a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.
    Note

    Follow the Governing Benefit or Plan Document

    Member-specific benefits and applicable plan documents govern coverage. If this policy conflicts with a plan document or individual insurance policy, the plan document or policy controls.

    • Consult group-specific policy and the member’s plan documents before rendering services.
    • For Medicare, CMS determines coverage; if CMS has not adopted a coverage determination, this policy applies.

    Purpose and Context

    CPT Category III codes are temporary AMA “T” codes used to collect data about emerging technologies, services, procedures, and service paradigms. The data may support documentation of widespread use or an FDA approval process. Category III procedures and services do not necessarily require FDA approval.

    Key Terms

    CPT Category III codes
    Code categoryCPT Category III codes
    Code formatTemporary AMA “T” codes
    PurposeAllow data collection for emerging technologies, services, procedures, and service paradigms
    Experimental, investigational, or unproven
    ClassificationExperimental, investigational, or unproven
    When it appliesWhen no other applicable Priority Health medical policy or Utilization Management delegate policy or guideline specifically addresses medical necessity for the Category III-coded item, service, or procedure
    Coverage implicationThe Category III-coded item, service, or procedure is considered experimental, investigational, or unproven under this policy