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    v1.0.28
    OpenPayerPolicy UpdatesLaboratory/PathologyPriority Health CPT Category III Coverage Update |…
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    Currentpriority healthPolicy N/A

    CPT Category III (Temporary 'T') Codes — Coverage and Coding Guidance

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    This policy governs Priority Health's coverage stance and coding guidance for AMA CPT Category III (temporary 'T') codes used for emerging technologies, procedures, and services, and affects providers billing these codes under Priority Health plans.

    Policy Summary
    Payerpriority health
    PolicyCPT Category III (Temporary 'T') Codes — Coverage and Coding Guidance
    Policy CodePolicy N/A
    Change TypeCoding table clarification
    Effective Date
    Last ReviewMay 13, 2026
    Next Review DateMay 13, 2026
    Key ActionWhen prior authorization is required, submit a request demonstrating medical necessity and reference any UM delegate program noted for the code (e.g., EviCore, TurningPoint).
    SourceLink
    POLICY UPDATE CHANGES

    Clarified I. MEDICAL NECESSITY CRITERIA.

    VI. CODING: Table lists only active Category III 'T' codes where at least one of the following applies: code does not appear in another Priority Health medical policy; code is considered not separately payable; or code is managed by one of Priority Health's Utilization Management delegates.

    ~120unique T-codes listed in this excerpt
    multiplecodes noted as Medically necessary
    severalcodes noted as Not Separately Payable
    severalcodes with external vendor notes
    6policy applies to product types

    Coverage Criteria for Category III (T) Codes

    General medical necessity stance for Category III codes

    Covered only when addressed by a specific Priority Health or UM delegate policy; otherwise considered experimental/investigational.

    General rule: Unless another Priority Health medical policy or a UM delegate medical policy/guideline specifically addresses medical necessity for a particular Category III code, the item, service or procedure represented by that Category III code is considered experimental, investigational or unproven.

    Refer to other Priority Health or UM delegate policies for codes that are managed elsewhere.

    Per-code notes (examples from coding table)

    Some Category III codes in the list have explicit notes indicating coverage stance or management.

    Not Separately Payable codes: Codes explicitly marked 'Not Separately Payable' (examples: 0174T, 0175T, 0351T–0354T, 0397T, and others in the coding table) should not be billed as separately payable services per the Notes.

    Billing separately may result in denial; see coding table entries for full list.

    Medically necessary codes: Certain codes are annotated 'Medically necessary' in the Notes (examples: 0184T, 0213T–0218T, 0235T–0238T, 0403T, 0575T–0579T, 0644T, 0652T–0654T, 0735T, 0786T–0787T, 0937T–0940T) and are covered when medical necessity is documented per applicable policy.

    Providers must submit supporting documentation consistent with member benefits and any referenced UM delegate criteria.

    Vendor/UM-managed codes: Several codes include vendor or UM program notes (for example, TurningPoint MSK/CV, EviCore Cardiology, Radiology & Ultrasound, EviCore Laboratory Management) indicating delegated prior authorization or external review may apply (examples include 0054T–0055T, 0075T–0076T, 0331T–0332T, 0609T–0612T, 0633T–0634T, 0648T–0649T, 0742T, 0794T, and others).

    When a vendor or delegate is referenced, follow that program's authorization and documentation requirements via Priority Health's Authorization Criteria Lookup.

    Per-code coverage notes

    Coverage annotations shown in the code list (per-code notes):

    Medically necessary annotations: Codes annotated as 'Medically necessary' in the coding table are covered when billed with appropriate documentation and when medical necessity is met (see individual code entries).

    Refer to each code's Notes field for specifics and any referenced UM delegate guidance.

    Not Separately Payable annotations: Codes annotated 'Not Separately Payable' in the coding table are not payable as separate services (examples include CAD chest radiograph codes 0174T/0175T, OCT breast/axillary codes 0351T–0354T, ERCP with optical endomicroscopy 0397T, and selected augmentative algorithm or imaging outputs).

    Billing these codes separately from the primary procedure may trigger denial.

    Not medically necessary annotations: Codes explicitly noted 'Not medically necessary' (example: 0518T) are not covered when billed as medically necessary services per the coding table annotation.

    Such codes may be denied if submitted as covered services.

    Medical Necessity and Individual Case Review

    Coverage and review process for Category III 'T' codes and investigational treatments

    Prior authorization when required: Prior authorization is required when specified by the member's plan or by referenced UM/delegate program; when prior authorization is required providers must submit a request demonstrating medical necessity.

    Access EviCore, InterQual, or TurningPoint guidelines via Priority Health Prism Authorization Criteria Lookup; see Priority Health Provider Manual for details.

    Individual case review for investigational care: Individual case review may permit coverage for investigational or unproven treatments in exceptional circumstances; requests require prior plan approval and will be adjudicated by a Priority Health medical director or clinical pharmacist.

    Exceptions considered for terminal illness or chronic, life‑threatening, severely disabling disease causing serious clinical deterioration.

    Delegation and table scope: The coding table lists only active Category III 'T' codes that: do not appear in another Priority Health medical policy, are considered Not Separately Payable, or are managed by a Priority Health UM delegate. Codes outside those conditions may be managed by separate policies or delegates.

    Priority Health treats CPT Category III (temporary 'T') codes as experimental, investigational, or unproven by default unless a specific Priority Health medical policy or a UM delegate (for example, EviCore or TurningPoint) explicitly addresses medical necessity for that code. When a code is governed by a separate Priority Health policy or by an identified UM delegate policy, providers must follow that policy or guideline for medical necessity and prior authorization requirements. Evidence of these referral rules and the general stance is shown in the coding section and medical necessity review guidance.

    Several individual Category III entries in the coding table include explicit payment or management notes that affect provider actions: codes marked Not Separately Payable should not be billed as standalone charges and may be denied if submitted separately (examples in the list include 0174T/0175T, 0351T–0354T, 0397T, 0523T, and numerous digitization/pathology slide codes). One code (0518T) is explicitly annotated as Not medically necessary and is at risk for denial when billed as a medically necessary service.

    Multiple Category III codes reference external utilization management or vendor review programs. Examples include codes with notes indicating EviCore Cardiology, Radiology, & Ultrasound or TurningPoint (MSK/CV) involvement (for example, 0331T/0332T, 0609T–0612T, 0633T–0634T, 0395T, and others). When such vendor references appear, prior authorization or management review may be required through the named vendor; providers should follow the vendor processes and submit documentation consistent with those external UM requirements.

    Specific code groups require additional provider documentation or ordering prerequisites. For example, algorithmic laboratory/oncology code 0794T requires previously interpreted and reported tumor-specific pathology or molecular results and references EviCore Laboratory Management, implying vendor-managed prior review and that ordering clinicians should include prior pathology/molecular reports with any prior authorization request.

    Prolonged external ECG monitoring codes (notably 0937T–0940T) are annotated Medically necessary in the table but remain subject to payer rules; prior authorization may be required per the member's plan or delegated UM criteria. Similarly, digitization and slide-scanning codes (0827T–0856T and related entries) are largely annotated Not Separately Payable, and providers should not submit them as separate billable services when they accompany a primary procedure.

    This policy's coding table intentionally lists only active Category III 'T' codes that meet at least one of these conditions: they are not addressed in another Priority Health medical policy; they are considered Not Separately Payable; or they are managed by one of Priority Health's Utilization Management delegates. Codes that appear in other Priority Health policies or are governed elsewhere are not repeated here — consult the applicable policy for coverage and billing guidance.

    When a code is annotated Not Separately Payable in the Notes, it means the service is not payable as an independent, standalone charge in addition to a primary procedure. Examples in the coding list include certain optical coherence tomography (0351T–0354T), computer-aided detection chest radiography entries (0174T/0175T), intraprocedural or intravascular adjunct imaging codes (e.g., 0984T–0987T) and many digitization/pathology slide codes (0827T–0856T). Billing these entries separately from the primary procedure can trigger denial.

    Some Category III codes are explicitly labeled Not medically necessary (for example, 0518T in the coding excerpt). Those codes are excluded from coverage when billed as medically necessary services unless an approved individual case review determines otherwise.

    A subset of codes includes vendor or UM vendor references (for example, EviCore or TurningPoint). Those references reflect delegated utilization management for prior authorization or coverage decisions; providers should follow the named vendor's submission requirements when the Notes indicate vendor-managed review.

    Certain monitoring and algorithmic codes are annotated Medically necessary in the Notes (for example, prolonged external ECG monitoring codes 0937T–0940T). Even where a code is labeled medically necessary, providers must still comply with plan-specific prior authorization rules and documentation requirements to secure payment.

    Providers should verify benefits and eligibility and include all required documentation when submitting prior authorization requests. Failure to follow prior authorization or vendor-managed processes, or submitting services marked Not Separately Payable as standalone claims, may result in denial or nonpayment.

    Code 0518T is specifically annotated in the coding section as Not medically necessary. Providers should not bill this code as a medically necessary service for Priority Health members unless an approved individual case review or an explicit delegated policy states otherwise.

    Several codes are flagged Not Separately Payable in the Notes field and therefore should not be billed independently from a primary procedure; examples include 0351T–0354T (OCT of breast/axillary tissue), 0397T (ERCP with optical endomicroscopy), and 0523T (intraprocedural coronary FFR with 3D mapping). Submitting these items as separate charges may prompt denial consistent with the payment-status annotation.

    Digitization and pathology slide-related Category III codes (for example, 0827T–0856T and related entries) carry Not Separately Payable annotations when they represent ancillary or consultative slide digitization services. These codes are intended to be billed in accordance with payer guidance and not separately when they are part of a primary pathology or surgical procedure.

    Where coding notes identify an external vendor or UM delegate (for example, EviCore or TurningPoint), those codes may require prior authorization or vendor-directed review to determine medical necessity and coverage. Providers must follow the referenced vendor's submission process and include the documentation the vendor requires.

    Overall, refer to the coding table Notes for each listed code to determine whether the code is Medically necessary, Not Separately Payable, vendor-managed, or otherwise restricted; follow the applicable prior authorization and documentation pathways to avoid payment denials.

    Prior Authorization

    0794T — require prior pathology results and EviCore Laboratory Management review

    0794T is annotated: "Patient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results which have been previously interpreted and reported separately." The Notes field specifically references EviCore Laboratory Management, indicating that prior authorization, vendor review, or the EviCore Laboratory Management process applies for coverage determination of this algorithmic laboratory service.

    • Provide previously interpreted and reported tumor-specific pathology/molecular results when requesting coverage.
    • Follow EviCore Laboratory Management processes for prior authorization or coverage review as referenced in the code Notes.

    Category III (T) CPT Codes

    Selected Category III CPT codes (excerpt)CPT
    0054TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image- guidance based on fluoroscopic images (List separately in addition to code for primary procedure). Notes = TurningPoint MSK.
    0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image- guidance based on CT/MRI images (List separately in addition to code for primary procedure). Notes = TurningPoint MSK.
    0075TTranscatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; initial vessel. Notes = TurningPoint CV.
    0076TTranscatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; each additional vessel (List separately in addition to code for primary procedure). Notes = TurningPoint CV.
    0098TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach; each additional interspace, cervical (List separately in addition to code for primary procedure). Notes = TurningPoint CV.
    0106TQuantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation.
    0107TQuantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation.
    0108TQuantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia.
    0109TQuantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia.
    0110TQuantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation.
    Additional Category III CPT codes (excerpt)CPT
    0110TQuantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation. 0110T, Notes = .
    0164TRemoval of total disc arthroplasty, anterior approach, lumbar, each additional interspace. Notes = TurningPoint MSK.
    0165TRevision of total disc arthroplasty, anterior approach, lumbar, each additional interspace. Notes = TurningPoint MSK.
    0174TComputer-aided detection (CAD) with further physician review for interpretation and report, chest radiograph(s), performed concurrent with primary interpretation (List separately). Notes = Not Separately Payable.
    0175TComputer-aided detection (CAD) with further physician review for interpretation and report, chest radiograph(s), performed remote from primary interpretation. Notes = Not Separately Payable.
    0184TExcision of rectal tumor, transanal endoscopic microsurgical approach (TEMS) including muscularis propria (full thickness). Notes = Medically necessary.
    0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), includes imaging guidance and bone biopsy when performed. Notes = TurningPoint MSK.
    0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, includes imaging guidance and bone biopsy when performed. Notes = TurningPoint MSK.
    0202TPosterior vertebral joint(s) arthroplasty including facetectomy, laminectomy, foraminotomy and vertebral column fixation, single level, lumbar. Notes = TurningPoint MSK.
    0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet joint with ultrasound guidance, cervical or thoracic; single level. Notes = Medically necessary.
    1–10 of 27
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    Further Category III CPT codes (excerpt)CPT
    0347TPlacement of interstitial device(s) in bone for radiostereometric analysis (RSA).
    0348TRadiologic examination, radiostereometric analysis (RSA); spine. Notes = .
    0349TRadiologic examination, RSA; upper extremity(ies). Notes = .
    0350TRadiologic examination, RSA; lower extremity(ies). Notes = .
    0351TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative. Notes = Not separately payable.
    0352TOptical coherence tomography of breast or axillary lymph node, excised tissue; interpretation and report, real time or referred. Notes = Not separately payable.
    0353TOptical coherence tomography of breast, surgical cavity; real time intraoperative. Notes = Not separately payable.
    0354TOptical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred. Notes = Not separately payable.
    0358TBioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report.
    0395THigh dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed. Notes = EviCore Radiation Oncology.
    1–10 of 11
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    Sample early T-codesCPT
    0332TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT.
    0342TTherapeutic apheresis with selective HDL delipidation and plasma reinfusion.
    0347TPlacement of interstitial device(s) in bone for radiostereometric analysis (RSA).
    Imaging, OCT, and preventive behavior codesCPT
    0348TRadiologic examination, radiostereometric analysis (RSA); spine.
    0349TRadiologic examination, radiostereometric analysis (RSA); upper extremity(ies).
    0350TRadiologic examination, radiostereometric analysis (RSA); lower extremity(ies).
    0351TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative.
    0352TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report.
    0353TOptical coherence tomography of breast, surgical cavity; real time intraoperative.
    0354TOptical coherence tomography of breast, surgical cavity; interpretation and report.
    0358TBioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report.
    0395THigh dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction.
    0397TEndoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy.
    1–10 of 11
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    Cardiac device, neurofibromata, tactile imaging codesCPT
    0408TInsertion or replacement of permanent cardiac contractility modulation system; pulse generator with transvenous electrodes.
    0409TInsertion or replacement of permanent cardiac contractility modulation system; pulse generator only.
    0410TInsertion or replacement of permanent cardiac contractility modulation system; atrial electrode only.
    0411TInsertion or replacement of permanent cardiac contractility modulation system; ventricular electrode only.
    0412TRemoval of permanent cardiac contractility modulation system; pulse generator only.
    0413TRemoval of permanent cardiac contractility modulation system; transvenous electrode.
    0419TDestruction neurofibromata, extensive, face, head and neck, greater than 50 neurofibromata.
    0420TDestruction neurofibromata, extensive, trunk and extremities, greater than 100 neurofibromata.
    0422TTactile breast imaging by computer-aided tactile sensors, unilateral or bilateral.
    0437TImplantation of non-biologic or synthetic implant for fascial reinforcement of the abdominal wall.
    1–10 of 11
    1/2
    Various device, ablation, regenerative therapy codesCPT
    0440TAblation, percutaneous, cryoablation; upper extremity distal/peripheral nerve.
    0441TAblation, percutaneous, cryoablation; lower extremity distal/peripheral nerve.
    0442TAblation, percutaneous, cryoablation; nerve plexus or other truncal nerve.
    0443TReal time spectral analysis of prostate tissue by fluorescence spectroscopy.
    0483TTranscatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach.
    0484TTranscatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure.
    0485TOptical coherence tomography (OCT) of middle ear, with interpretation and report; unilateral.
    0486TOptical coherence tomography (OCT) of middle ear, with interpretation and report; bilateral.
    0488TPreventive behavior change, online/electronic structured intensive program for prevention of diabetes; individual, per 30 days.
    0489TAutologous adipose-derived regenerative cell therapy for scleroderma in the hands; harvesting and preparation.
    1–10 of 17
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    Monitoring, imaging, 3D-printing, and autologous therapy codesCPT
    0523TIntraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping (List separately).
    0525TInsertion or replacement of intracardiac ischemia monitoring system; complete system.
    0541TMyocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, single study.
    0542TMyocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia; interpretation and report.
    0546TRadiofrequency spectroscopy, real time, intraoperative margin assessment at partial mastectomy.
    0558TComputed tomography scan for biomechanical computed tomography analysis.
    0559TAnatomic model 3D-printed from image data set(s); first component.
    0560TAnatomic model 3D-printed; each additional component.
    0561TAnatomic guide 3D-printed and designed; first guide.
    0562TAnatomic guide 3D-printed; each additional guide.
    1–10 of 13
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    Remaining codes in excerptCPT
    0571TInsertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s).
    0572TInsertion of substernal implantable defibrillator electrode.
    0573TRemoval of substernal implantable defibrillator electrode.
    0574TRepositioning of previously implanted substernal implantable defibrillator-pacing electrode.
    0575TProgramming device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode.
    0576TInterrogation device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode.
    0577TElectrophysiological evaluation of implantable cardioverter-defibrillator system with substernal electrode.
    0578TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead ICD system with interim analysis.
    0579TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead ICD system remote data acquisition and technician review.
    0580TRemoval of substernal implantable defibrillator pulse generator only.
    1–10 of 33
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    T-Code Procedures ListedCPT
    0609TMagnetic resonance spectroscopy ... in at least 3 discs. Notes = EviCore Cardiology, Radiology, & Ultrasound
    0610TMagnetic resonance spectroscopy, determination and localization of discogenic pain; transmission of biomarker data for software analysis. Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0611TMagnetic resonance spectroscopy ... postprocessing for algorithmic analysis of biomarker data. Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0612TMagnetic resonance spectroscopy ... interpretation and report. Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0613TPercutaneous transcatheter implantation of interatrial septal shunt device... Notes = .
    0615TAutomated analysis of binocular eye movements... for assessment of concussion, with interpretation and report. Notes = .
    0632TPercutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries... Notes = .
    0633TComputed tomography, breast, including 3D rendering, unilateral; without contrast material. Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0634TComputed tomography, breast, including 3D rendering, unilateral; with contrast material(s). Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0635TComputed tomography, breast, including 3D rendering, unilateral; without contrast, followed by contrast material(s). Notes = EviCore Cardiology, Radiology, & Ultrasound.
    1–10 of 37
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    Selected device and algorithm codes (excerpt)CPT
    0794TPatient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results which have been previously interpreted and reported separately. Notes = EviCore Laboratory Management.
    0795TTranscatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance and device evaluation; complete system. Notes = TurningPoint CV.
    0796TTranscatheter insertion of permanent dual-chamber leadless pacemaker; right atrial pacemaker component when an existing right ventricular single leadless pacemaker exists. Notes = TurningPoint CV.
    0797TTranscatheter insertion of permanent dual-chamber leadless pacemaker; right ventricular pacemaker component when part of a dual-chamber system. Notes = TurningPoint CV.
    0798TTranscatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance; complete system. Notes = TurningPoint CV.
    Device/programming/valve procedure codesCPT
    0799TTranscatheter removal of permanent dual-chamber leadless pacemaker; right atrial component.
    0800TTranscatheter removal of permanent dual-chamber leadless pacemaker; right ventricular component.
    0801TTranscatheter removal and replacement of permanent dual-chamber leadless pacemaker; dual-chamber system.
    0802TTranscatheter removal and replacement of permanent dual-chamber leadless pacemaker; right atrial component.
    0803TTranscatheter removal and replacement of permanent dual-chamber leadless pacemaker; right ventricular component.
    0804TProgramming device evaluation (in person) with iterative adjustment of implantable device, leadless pacemaker system in dual cardiac chambers, with analysis, review, and report.
    0806TTranscatheter superior and inferior vena cava prosthetic valve implantation (caval valve implantation); open femoral vein approach.
    Digitization and pathology slide-related codesCPT
    0827TDigitization of glass microscope slides for cytopathology, fluids, washings, or brushings, except cervical or vaginal; smears with interpretation.
    0828TDigitization of glass microscope slides for cytopathology; simple filter method with interpretation.
    0829TDigitization of glass microscope slides for cytopathology, concentration technique, smears, and interpretation (eg, Saccomanno technique).
    0830TDigitization of glass microscope slides for cytopathology, selective-cellular enhancement technique with interpretation (eg, liquid-based slide preparation method), except cervical or vaginal.
    0831TDigitization of glass microscope slides for cytopathology, cervical or vaginal; requiring interpretation by physician.
    0832TDigitization of glass microscope slides for cytopathology, smears, any other source; screening and interpretation.
    0833TDigitization of glass microscope slides for cytopathology, smears, any other source; preparation, screening and interpretation.
    0834TDigitization of glass microscope slides for cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains.
    0835TDigitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site.
    0836TDigitization of glass microscope slides for cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study, each separate additional evaluation episode.
    1–10 of 30
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    Miscellaneous imaging, augmentative analysis, device, and novel procedure codesCPT
    0857TOpto-acoustic imaging, breast, unilateral, including axilla when performed, real-time with image documentation, augmentative analysis and report.
    0858TExternally applied transcranial magnetic stimulation with concomitant measurement of evoked cortical potentials with automated report.
    0859TNoncontact near-infrared spectroscopy ... each additional anatomic site.
    0860TNoncontact near-infrared spectroscopy for screening for peripheral arterial disease, including provocative maneuvers, image acquisition, interpretation, and report, one or both lower extremities.
    0861TRemoval of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components.
    0862TRelocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only.
    0863TRelocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; transmitter component only.
    0865TQuantitative MRI analysis of the brain with comparison to prior MR study(ies), including lesion identification, characterization, and quantification, with brain volume(s) quantification and/or severity score, obtained without diagnostic MRI of the same anatomy. Notes = EviCore Cardiology, Radiology, & Ultrasound.
    0866TQuantitative MRI analysis of the brain with comparison to prior MR study(ies), obtained with diagnostic MRI exam of the brain.
    0870TImplantation of subcutaneous peritoneal ascites pump system, percutaneous, including pump-pocket creation, insertion of tunneled indwelling bladder and peritoneal catheters with pump connections, including all imaging and initial programming.
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    Coding block 0892T–0902TCPT
    0892TAccelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent motor threshold redetermination with delivery and management, per treatment day.
    0893TNoninvasive assessment of blood oxygenation, gas exchange efficiency, and cardiorespiratory status, with physician or other qualified health care professional interpretation and report.
    0897TNoninvasive augmentative arrhythmia analysis derived from quantitative computational cardiac arrhythmia simulations, based on selected intervals of interest from 12-lead electrocardiogram and uploaded clinical parameters, including interpretation and report.
    0898TNoninvasive prostate cancer estimation map, derived from augmentative analysis of image-guided fusion biopsy and pathology, including visualization of margin volume and location, with margin determination and physician interpretation and report.
    0899TNoninvasive determination of absolute quantitation of myocardial blood flow (AQMBF), derived from augmentative algorithmic analysis of dataset acquired via contrast cardiac magnetic resonance (CMR), pharmacologic stress, with interpretation and report by a physician (List separately). Notes = Not Separately Payable.
    0900TNoninvasive estimate of absolute quantitation of myocardial blood flow (AQMBF), derived from assistive algorithmic analysis of dataset acquired via contrast CMR, pharmacologic stress, with interpretation and report by a physician (List separately). Notes = Not Separately Payable.
    0901TPlacement of bone marrow sampling port, including imaging guidance when performed.
    0902TQTc interval derived by augmentative algorithmic analysis of input from an external, patient-activated mobile ECG device. Notes = Not Separately Payable.
    Coding block 0903T–0912TCPT
    0903TElectrocardiogram, algorithmically generated 12-lead ECG from a reduced-lead ECG; with interpretation and report. Notes = Not Separately Payable.
    0904TElectrocardiogram, algorithmically generated 12-lead ECG from a reduced-lead ECG; tracing only. Notes = Not Separately Payable.
    0905TElectrocardiogram, algorithmically generated 12-lead ECG from a reduced-lead ECG; interpretation and report only. Notes = Not Separately Payable.
    0906TConcurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; first application, total wound(s) surface area <= 50 sq cm.
    0907TConcurrent optical and magnetic stimulation (COMS) therapy; each additional application.
    0908TOpen implantation of integrated neurostimulation system, vagus nerve, including analysis and programming.
    0909TReplacement of integrated neurostimulation system, vagus nerve, including analysis and programming.
    0910TRemoval of integrated neurostimulation system, vagus nerve.
    0911TElectronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming.
    0912TElectronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming.
    Coding block 0913T–0931TCPT
    0913TPercutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon, including endoluminal imaging when performed. Notes = TurningPoint CV.
    0914TPercutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon on a separate target lesion (List separately). Notes = TurningPoint CV.
    0915TInsertion of permanent cardiac contractility modulation-defibrillation system component(s); pulse generator and dual transvenous electrodes.
    0916TInsertion of permanent cardiac contractility modulation-defibrillation system component(s); pulse generator only.
    0917TInsertion of permanent cardiac contractility modulation-defibrillation system component(s); single transvenous lead only.
    0918TInsertion of permanent cardiac contractility modulation-defibrillation system component(s); dual transvenous leads only.
    0919TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); pulse generator only.
    0920TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only.
    0921TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only.
    0922TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); dual transvenous leads only.
    1–10 of 19
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    Coding block 0932T–0944TCPT
    0932TNoninvasive detection of heart failure derived from augmentative analysis of an echocardiogram.
    0934TRemote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data uploads, interpretation and trend analysis.
    0935TCystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach.
    0936TPhotobiomodulation therapy of retina, single session.
    0937TExternal electrocardiographic recording for greater than 15 days up to 30 days including recording, scanning analysis with report. Notes = Medically necessary.
    0938TExternal electrocardiographic recording for greater than 15 days up to 30 days; recording (including connection and initial recording). Notes = Medically necessary.
    0939TExternal electrocardiographic recording for greater than 15 days up to 30 days; scanning analysis with report. Notes = Medically necessary.
    0940TExternal electrocardiographic recording for greater than 15 days up to 30 days; review and interpretation by a physician. Notes = Medically necessary.
    0944T3D contour simulation of target liver lesion(s) and margin(s) for image-guided percutaneous microwave ablation. Notes = Not Separately Payable.
    Coding block 0945T–0955TCPT
    0945TIntraoperative assessment for abnormal (tumor) tissue, in-vivo, following partial mastectomy using computer-aided fluorescence imaging (List separately).
    0946TOrthopedic implant movement analysis using paired CT examination of the target structure, including data acquisition, data preparation and transmission, interpretation and report.
    0947TMagnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators, including stereotactic navigation and frame placement.
    0948TInterrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system with interim analysis, review and report(s).
    0949TInterrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system, remote data acquisition(s), technician review, technical support, and distribution of results.
    0950TAblation of benign prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance.
    0951TTotally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor.
    0952TTotally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor.
    0953TTotally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor.
    0954TTotally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers.
    1–10 of 11
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    Coding block 0956T–0962TCPT
    0956TPartial craniectomy, channel creation, and tunneling of electrode for sub-scalp implantation of an electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance.
    0957TRevision of sub-scalp implanted electrode array, receiver, and telemetry unit for electrode, when required, including imaging guidance.
    0958TRemoval of sub-scalp implanted electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance.
    0959TRemoval or replacement of magnet from coil assembly that is connected to continuous bilateral electroencephalography monitoring system, including imaging guidance.
    0960TReplacement of sub-scalp implanted electrode array, receiver, and telemetry unit with tunneling of electrode for continuous bilateral electroencephalography monitoring system, including imaging guidance.
    0961TShortwave infrared radiation imaging, surgical pathology specimen, to assist gross examination for lymph node localization in fibroadipose tissue, per specimen (List separately). Notes = Not Separately Payable.
    0962TAssistive algorithmic analysis of acoustic and electrocardiogram recording for detection of cardiac dysfunction, with review and interpretation by a physician. Notes = Not Separately Payable.
    Coding block 0963T–0971TCPT
    0963TAnoscopy with directed submucosal injection of bulking agent into anal canal.
    0964TImpression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism.
    0965TImpression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea; dual arch, with additional mandibular advancement, non-fixed hinge mechanism.
    0966TImpression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea; dual arch, with additional mandibular advancement, fixed hinge mechanism.
    0967TTransanal insertion of endoluminal temporary colorectal anastomosis protection device, including vacuum anchoring component and flexible sheath connected to external vacuum source and monitoring system.
    0968TInsertion or replacement of epicranial neurostimulator system, including electrode array and pulse generator, with connection to electrode array.
    0969TRemoval of epicranial neurostimulator system.
    0970TAblation, benign breast tumor (eg, fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor.
    0971TAblation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral.
    Coding block 0972T–0981TCPT
    0972TAssistive algorithmic classification of burn healing by noninvasive multispectral imaging, including system set-up and acquisition, selection, and transmission of images, with automated generation of report.
    0973TSelective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia, including patient monitoring, trunk, arms, legs; first 100 sq cm.
    0974TSelective enzymatic debridement, each additional 100 sq cm (List separately).
    0975TSelective enzymatic debridement, scalp/neck/hands/feet/multiple digits; first 100 sq cm.
    0976TSelective enzymatic debridement, each additional 100 sq cm for scalp/neck/hands/feet/multiple digits (List separately).
    0977TUpper gastrointestinal blood detection, sensor capsule, with interpretation and report.
    0978TSubmucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil.
    0979TSubmucosal cryolysis therapy; soft palate only.
    0980TSubmucosal cryolysis therapy; base of tongue and lingual tonsil only.
    0981TTranscatheter implantation of wireless inferior vena cava sensor for long-term hemodynamic monitoring, including deployment, radiological supervision and interpretation, right heart catheterization, and inferior vena cava venography when performed.
    Coding block 0982T–0996TCPT
    0982TRemote monitoring of implantable inferior vena cava pressure sensor, physiologic parameter(s), initial set-up and patient education on equipment.
    0983TRemote monitoring of an implanted inferior vena cava sensor for up to 30 days, including at least weekly downloads, interpretation(s), trend analysis, and report(s).
    0984TIntravascular imaging of extracranial cerebral vessels using OCT; initial vessel (List separately). Notes = Not Separately Payable.
    0985TIntravascular imaging of extracranial cerebral vessels using OCT; each additional vessel. Notes = Not Separately Payable.
    0986TIntravascular imaging of intracranial cerebral vessels using OCT; initial vessel. Notes = Not Separately Payable.
    0987TIntravascular imaging of intracranial cerebral vessels using OCT; each additional vessel. Notes = Not Separately Payable.
    0988TOpen insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) and pulse generator or receiver, posterior tibial nerve; subcutaneous and subfascial.
    0989TRevision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, posterior tibial nerve; subcutaneous and subfascial.
    0990TTranscervical instillation of biodegradable hydrogel materials, intrauterine.
    0991TCystourethroscopy, with low-energy lithotripsy and acoustically actuated microspheres, including imaging.
    1–10 of 15
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    Category III 'T' codes (excerpt)CPT
    0988TInsertion of neurostimulation system posterior tibial nerve; subcutaneous and subfascial (including analysis, programming, imaging guidance, pulse generator or receiver).
    Category III 'T' codes (excerpt)CPT
    0989TRevision or removal of integrated neurostimulation system for bladder dysfunction, posterior tibial nerve; including analysis, programming, imaging.
    0990TTranscervical instillation of biodegradable hydrogel materials, intrauterine.
    0991TCystourethroscopy with low-energy lithotripsy and acoustically actuated microspheres, including imaging.
    0992TNoninvasive assessment of cardiac risk derived from augmentative software analysis of perivascular fat without concurrent CT of heart, with interpretation and report.
    0993TNoninvasive assessment of cardiac risk derived from augmentative software analysis of perivascular fat with concurrent CT scan of heart, with interpretation and report.
    0994TEndovascular delivery of aortic wall stabilization drug therapy through a sheath within an abdominal aortic aneurysm; percutaneous.
    0995TEndovascular delivery of aortic wall stabilization drug therapy through a sheath within an abdominal aortic aneurysm; open.
    0996TInsertion and scleral fixation of a capsular bag prosthesis containing an intraocular lens prosthesis, with vitrectomy, including removal of crystalline lens or dislocated intraocular lens prosthesis.
    Category III 'T' codes (continued)CPT
    0997TPrecuneus magnetic stimulation; treatment planning using MRI-guided neuronavigation derived from evoked potentials with automated data processing, analysis, generation of treatment parameters with review and report.
    0998TPrecuneus magnetic stimulation; personalized treatment delivery per day using MRI-based neuronavigation.
    0999TAutologous muscle cell therapy, harvesting of muscle progenitor cells, including ultrasound guidance.
    1000TAutologous muscle cell therapy, administration into urethral sphincter, including cystoscopy and post-void residual ultrasound.
    1001TAutologous muscle cell therapy, injection into external anal sphincter, including ultrasound guidance.
    1002TAir displacement plethysmography, whole-body composition assessment, with interpretation and report.
    1003TArthroplasty, first carpometacarpal joint, with distal trapezial and proximal first metacarpal prosthetic replacement.
    1004TElectronic analysis of implanted sub-scalp continuous bilateral EEG monitoring system by physician; without programming.
    1005TElectronic analysis of implanted sub-scalp continuous bilateral EEG monitoring system; with programming, first 15 minutes face-to-face.
    1006TElectronic analysis of implanted sub-scalp continuous bilateral EEG monitoring system; with programming, each additional 15 minutes face-to-face.
    1–10 of 26
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    Category III code criteria
    DefinitionCategory III CPT codes are temporary 'T' codes for data collection on emerging technologies, services, procedures, and service paradigms; inclusion does not establish clinical efficacy, safety, or payer coverage.
    Reasons codes may be Category III (do not meet Category I requirements)

    Provider Actions, Prior Authorization, and Billing Guidance

    Note

    Refer to separate Priority Health or UM-delegate policies

    Some Category III 'T' codes are managed through separate Priority Health medical policies or by Priority Health UM delegates; providers must refer to the applicable Priority Health or UM delegate medical policy or guideline for medical necessity and prior authorization requirements.

    Prior Authorization

    Vendor-directed prior authorization may apply

    Several imaging and spectroscopy Category III codes include notes referencing external vendors such as EviCore Cardiology, Radiology, & Ultrasound or TurningPoint CV; providers should anticipate that prior authorization or utilization management review may be required through those vendors.

    Prior Authorization

    Codes flagged for external review or delegated management

    Multiple Category III codes include payer notes referencing external management organizations (for example, EviCore or TurningPoint) indicating that prior authorization, case management, or external review processes may govern coverage decisions for those codes.

    Ordering Requirements and Preconditions

    Documentation Required

    0794T ordering requirement — prior interpreted pathology/molecular results

    0794T requires that the patient's tumor-specific molecular, immunohistochemical, or other pathology results have been previously interpreted and reported separately; ordering clinicians should ensure those prior pathology/molecular results exist and are documented.

    • Prior molecular/pathology results must be previously interpreted and reported.
    • Ordering is implied to be by oncology/pathology teams familiar with tumor markers.

    Covered Indications and Code-Specific Notes

    0794T - algorithm for ranking pharmaco-oncologic treatment options based on previously interpreted tumor-specific pathology results

    0794T describes a patient-specific algorithmic ranking of pharmaco-oncologic treatment options and has vendor/UM linkage and ordering expectations.

    Required data: 0794T applies only when the ranking algorithm uses the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results that have been previously interpreted and reported separately.

    The code description specifies prior interpreted pathology/molecular results are required.

    Vendor management: Notes for 0794T reference EviCore Laboratory Management, indicating that coverage review or prior authorization may be managed through that laboratory management program.

    Follow EviCore Laboratory Management processes for prior authorization or coverage determination as referenced in the coding Notes.

    Ordering considerations: Ordering should be performed only after requisite pathology/molecular results are available and interpreted; implied ordering clinicians include oncology and pathology teams involved in treatment selection.

    Not Covered / Not Separately Payable Items

    Code 0737T is noted in the coding list as Not Separately Payable, which excludes it from separate reimbursement when billed in addition to a primary procedure.

    A group of digitization and pathology slide-related Category III codes (including but not limited to 0827T–0856T series and related entries) are annotated as Not Separately Payable. These codes should not be billed separately from the associated primary pathology or surgical procedure; separate reimbursement may be denied per the Notes field.

    Definitions and Acronyms

    CPT Category III codes
    DefinitionCPT Category III codes are temporary ('T') CPT codes for tracking emerging technologies, services, procedures, and service paradigms; inclusion does not imply coverage or clinical efficacy.
    PurposeUsed for data collection to substantiate widespread usage or support FDA documentation/approval, not to establish standard of care.
    Policy stancePriority Health treats Category III codes as experimental/investigational unless addressed by a specific Priority Health or UM delegate policy.
    TurningPoint CV / EviCore Cardiology, Radiology, & Ultrasound
    Vendor/UM program referencesSeveral codes include vendor notes naming utilization management programs (eg, EviCore Laboratory Management for 0794T; TurningPoint CV for multiple cardiac device codes).
    Effect on prior authorization

    Background

    CPT Category III codes are temporary ('T') codes created by the AMA to collect data on emerging technologies, procedures, services, and service paradigms. Inclusion of a Category III code in this policy or coding list does not by itself establish clinical efficacy, safety, or payer coverage. Because Category III codes often lack widespread clinical adoption or regulatory clearance, Priority Health treats them as generally experimental, investigational, or unproven unless a specific Priority Health policy or a UM-delegate guideline indicates otherwise.

    Revision History

    2026-05-13Last review / UpdatedLatest

    Committee review and document updates including clarification to I. MEDICAL NECESSITY CRITERIA; document marked as updated on 05/13/2026.

    05/2025Past review

    Policy underwent routine past review in May 2025 (listed in past review dates).

    05/2024Past review
    Policy Summary
    Payerpriority health
    PolicyCPT Category III (Temporary 'T') Codes — Coverage and Coding Guidance
    Policy CodePolicy N/A
    Change TypeCoding table clarification
    Effective Date
    Last ReviewMay 13, 2026
    Next Review DateMay 13, 2026
    Key ActionWhen prior authorization is required, submit a request demonstrating medical necessity and reference any UM delegate program noted for the code (e.g., EviCore, TurningPoint).
    SourceLink
    On This Page
    Coverage Criteria for Category III (T) CodesCategory III (T) CPT CodesProvider Actions, Prior Authorization, and Billing GuidanceOrdering Requirements and PreconditionsCovered Indications and Code-Specific NotesNot Covered / Not Separately Payable ItemsDefinitions and AcronymsBackgroundRevision History
    Vendor-reviewed / external review annotations: Codes that reference EviCore, TurningPoint, or other named vendor programs in their Notes indicate that external utilization management or vendor review may govern prior authorization and coverage determinations (examples include myocardial imaging codes 0331T–0332T, MR spectroscopy 0609T–0612T, breast CT/3D rendering 0633T–0636T, and algorithmic laboratory code 0794T).

    Providers should follow the authorization and documentation processes of the referenced vendor or Priority Health's delegated criteria lookup.

    Refer to other Priority Health policies for codes managed elsewhere; absent such policy the default stance is investigational/investigational/unproven.

    Operational and billing implications: payment-status flags present in the Notes (for example, Not Separately Payable or Medically necessary) may directly affect reimbursement. Failure to obtain prior authorization when required or to follow the referenced vendor/UM process may result in claim denial. Providers must verify member benefits and eligibility, include appropriate supporting documentation for medical necessity, and consult the Priority Health Provider Manual or Authorization Criteria Lookup for delegated guideline sources (EviCore, InterQual, TurningPoint) before submitting claims.

    Devices/drugs lacking FDA clearance when required; not widely performed by physicians nationally; insufficient procedure volume for intended use; not consistent with current medical practice; clinical efficacy not documented per CPT code change requirements.
    RVU/valuation noteCategory III codes are not referred to the AMA-RUC for valuation and have no assigned RVUs; payment is determined by payer policy.
    PurposeIntended to facilitate data collection to substantiate widespread use or support FDA documentation/approval processes.
    MCG channel minimum
    MCG minimum channelsMyocardial imaging by magnetocardiography (MCG) requires a minimum 36-channel grid.
    Example codes referencing vendors0710T and related MCG/augmentative imaging entries reference EviCore Cardiology, Radiology, & Ultrasound for management.
    ContextVendor-noted entries indicate external utilization management processes may apply to these imaging modalities.
    OCT remote surveillance recordings
    OCT remote surveillance recordingsOCT of the retina (remote surveillance) requires a minimum of 8 daily recordings, each 30 days (per 0605T).
    Associated services0604T covers initial device provision, set-up and patient education for patient-initiated OCT remote capture; 0606T covers physician review/interpretation each 30 days.
    NotesEntries reference remote surveillance center technical support, data analyses and reports as part of the service.
    Magnetic resonance spectroscopy discs
    Minimum number of discsMagnetic resonance spectroscopy for discogenic pain requires acquisition of single-voxel biomarker data in at least 3 discs (0609T).
    Related technical services0610T–0612T cover transmission, postprocessing/algorithmic analysis, and interpretation/report of MRS biomarker data; notes reference EviCore Cardiology, Radiology, & Ultrasound.
    Anatomic scopeApplies to cervical, thoracic, or lumbar discs as described in the MRS code definitions.
    Anatomic sites / number of discs
    Example requirementAnatomic involvement: MRS (0609T) specifies biomarkers obtained in at least 3 discs for localization of discogenic pain.
    Codes illustrating requirement0609T description explicitly references 'in at least 3 discs' and 0610T–0612T relate to processing/transmission and interpretation for these data.
    Clinical scopeApplies to cervical, thoracic, or lumbar disc assessments as noted in the code descriptors.
    Digitization extended study threshold
    Extended study thresholdDigitization codes for cytopathology indicate an 'extended study' involves over 5 slides and/or multiple stains (0834T).
    Related digitization codesMultiple digitization entries (0827T–0856T) reference specific specimen types and study levels tied to the extended study threshold.
    Payment guidanceMany digitization slide codes are noted 'Not Separately Payable' when billed in addition to a primary procedure.
    Active Category III codes listing rule
    Active codes listing ruleThe coding table lists only active Category III 'T' codes where at least one of these applies: code does not appear in another Priority Health policy; code is considered not separately payable; or code is managed by a Priority Health Utilization Management delegate.
    Implication for omitted codesCategory III codes that appear in other Priority Health policies, are inactive, or are not separately payable may be omitted from this table.
    Provider actionProviders should check other Priority Health medical policies and UM delegate guidelines for codes not listed here.
    Category III CPT codes ('T') listed in coding table
    Category III 'T' codes includedThis table contains numerous Category III 'T' codes (for example 0794T, 0609T, 0610T–0612T, 0633T–0634T and many others) listed with descriptions and Notes fields.
    Examples of 'T' codes0794T (algorithmic pharmaco‑oncologic ranking), 0609T (MRS for discogenic pain), 0633T/0634T (CT breast with 3D rendering) are among codes shown in the coding table.
    Notes and managementMany 'T' codes include Notes indicating payment status or vendor/UM management (eg, EviCore, TurningPoint) which affect coverage and prior authorization processes.
    Prior Authorization

    Vendor-review referenced codes may require management review

    Certain procedure codes list vendor notes (EviCore or TurningPoint CV) in the Notes field; when these notes appear, providers should expect that prior authorization or management review may be required via those external programs.

    Prior Authorization

    Prolonged external ECG monitoring: check prior authorization

    External ECG monitoring codes 0937T–0940T are annotated 'Medically necessary' in the Notes; providers should verify prior authorization requirements with the payer for prolonged external ECG monitoring services.

    Prior Authorization

    Prior authorization may be required—consult authorization resources

    Prior authorization may be required for certain drugs, devices, services and procedures including some Category III codes; providers must consult the Priority Health Provider Manual and Authorization Criteria Lookup for delegated guideline sources.

    Documentation Required

    Confirm member benefits and document medical necessity

    Coverage is subject to the member's specific benefits and eligibility; providers must document and submit evidence supporting medical necessity consistent with the member's plan and any referenced Priority Health or UM delegate policies.

    Documentation Required

    Include external UM program documentation when applicable

    When a code's Notes reference an external UM program (eg, TurningPoint CV or EviCore), include any documentation required by that program with the authorization or claim submission.

    Billing Rule

    Adhere to 'Medically necessary' and 'Not Separately Payable' notes

    Codes annotated 'Medically necessary' or 'Not Separately Payable' affect billing and coverage; providers must ensure documentation supports medical necessity where indicated and avoid billing codes marked 'Not Separately Payable' as separate charges.

    Documentation Required

    Align documentation with vendor-managed code requirements

    Some Category III procedure codes include vendor/management notes (for example, EviCore or TurningPoint CV); documentation and prior authorization submissions should align with the requirements of those vendor programs when referenced.

    Billing Rule

    Follow Notes guidance when submitting CPT/T codes

    Each listed procedure includes a description and a Notes field specifying payment or billing guidance (such as 'Not Separately Payable' or 'Medically necessary'); providers must submit CPT/T codes with supporting documentation consistent with those Notes.

    Documentation Required

    Submit medical necessity documentation for prior authorization

    When prior authorization is required, providers must submit a request demonstrating medical necessity and may need to reference vendor guidelines (EviCore, InterQual, or TurningPoint) via Priority Health's Authorization Criteria Lookup.

    Denial Risk

    Risk of denial: experimental/investigational stance

    Unless a Category III code is addressed by another Priority Health or UM delegate policy/guideline, services represented by Category III codes are considered experimental, investigational, or unproven and may be denied.

    Denial Risk

    Risk of denial for 'Not Separately Payable' codes

    Codes flagged as 'Not Separately Payable' (for example, 0397T, 0439T, 0523T and many digitization/pathology entries) should not be billed as separate payable claims; submitting them separately may trigger denial.

    Denial Risk

    0518T — Not medically necessary (denial risk)

    Code 0518T is explicitly noted as 'Not medically necessary' in the coding list; billing this code as medically necessary may result in denial.

    Prior Authorization

    External review references may trigger delegated review

    Some codes reference external review management programs (for example, EviCore Cardiology, Radiology, & Ultrasound); when such notes appear, prior authorization or external review processes may be triggered and coverage decisions delegated.

    Billing Rule

    Do not bill digitization/pathology 'Not Separately Payable' codes separately

    Digitization and glass-slide pathology codes (for example, 0827T–0856T and related codes) are annotated 'Not Separately Payable' and should not be billed as separate payable services; doing so may lead to denial.

    Denial Risk

    Payment-status flags affect reimbursement risk

    Codes with payment-status flags in the Notes (such as 'Not Separately Payable' or 'Medically necessary') can affect reimbursement; ensure claims and documentation are consistent with those flags to avoid denials or payment issues.

    Denial Risk

    Obtain prior authorization to avoid denials; individual case review required for exceptions

    Failure to obtain required prior authorization when specified may result in claim denial; investigational or unproven treatments often require individual case review and prior plan approval for exceptions.

    Providers must document the previously interpreted pathology/molecular reports when requesting coverage.

    Prior authorization and documentation: If prior authorization is required, submit clinical documentation demonstrating the previously interpreted pathology/molecular results and the intended use of the algorithmic ranking to inform pharmaco-oncologic treatment selection.

    Refer to Priority Health Provider Manual and Authorization Criteria Lookup for vendor-specific submission requirements (EviCore).

    Vendor notes indicate certain codes may be subject to delegated prior authorization or external review processes coordinated via those vendors.
    Provider actionProviders should follow the referenced vendor or UM delegate submission and documentation requirements when Notes indicate such linkage.
    Not Separately Payable
    Not Separately Payable (definition)An annotation indicating the listed digitization or ancillary pathology code should not be billed separately in addition to a primary procedure; separate billing may be denied.
    ExamplesDigitization of glass slide codes (0827T–0856T and related entries) are repeatedly noted as 'Not Separately Payable'.
    Billing riskSubmitting these codes as separately payable charges may result in claim denial per the Notes fields.
    0794T - algorithm for ranking pharmaco-oncologic treatment options
    0794T descriptionPatient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results previously interpreted and reported separately.
    Notes0794T Notes reference EviCore Laboratory Management.
    Ordering implicationRequires previously interpreted pathology/molecular results to be available and reported separately prior to applying the algorithm.

    Policy underwent routine past review in May 2024 (listed in past review dates).

    05/2023Past review

    Policy underwent routine past review in May 2023 (listed in past review dates).

    unspecified (Changes section)Coding table revision

    VI. CODING revised: table now lists only active Category III 'T' codes meeting at least one of three conditions (not appearing in another Priority Health policy; considered not separately payable; or managed by a Priority Health UM delegate).