ModifiedUnitedHealthcarePolicy MMP043.47

Category III CPT Codes

This UnitedHealthcare Medicare Advantage medical policy provides coverage conclusions and guidance for AMA Category III CPT codes—temporary codes tracking emerging technologies and procedures—and directs providers on where to find applicable Medicare or UnitedHealthcare coverage rules.

Policy Summary

PayerUnitedHealthcare

PolicyCategory III CPT Codes

Policy CodePolicy MMP043.47

Change TypeRevised CPT listremoved tethering codes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionConfirm whether a Medicare NCD/LCD/LCA applies; if none exists, follow the UnitedHealthcare Medicare Advantage Medical Policy guidance for the specific Category III code or related UnitedHealthcare policy.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable CPT codes; removed content/language addressing anterior lumbar or thoracolumbar vertebral body tethering (CPT codes 0656T and 0657T) and revision/replacement/removal of thoracolumbar or lumbar vertebral body tethering (CPT code 0790T).

Updated list of Centers for Medicare & Medicaid Services (CMS) related documents available in the Medicare Coverage Database.

100+Codes listed/discussed

ManyConcluded Not Reasonable

SomeRefer to NCD/LCD

1 NCDLeadless pacemaker NCD refs

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Coverage Conclusions and Criteria

Coverage Conclusions

Coverage conclusions for listed Category III CPT codes:

Not Reasonable and Necessary: Multiple Category III codes are concluded as Not Reasonable and Necessary and the policy directs to specific UnitedHealthcare Commercial Medical Policies for related coverage guidance (examples include 0202T, 0238T, 0263T-0265T, 0278T, 0342T, 0483T, 0484T, 0489T-0490T, 0505T, 0512T-0513T, 0565T-0566T, 0582T, 0598T-0599T, 0619T, 0627T-0630T, 0633T-0637T, 0638T, 0655T, 0687T-0688T, 0693T, 0704T-0706T)

See individual code lines for associated referenced UnitedHealthcare policy.

Refer to NCD/LCD: Some codes are to be referred to an applicable NCD or LCD/LCA for coverage determination (examples: 0464T — NGS L36831; 0564T — NCD 190.7; 0569T/0570T/0646T — respective transcatheter NCDs; multiple leadless pacemaker codes 0795T–0826T refer to NCD 20.8.4; 0736T — Colonic Irrigation NCD 100.7).

When an NCD/LCD exists, follow that determination rather than this policy.

For states without LCDs/LCAs: For codes where CMS LCD/LCA coverage criteria exist only in certain jurisdictions, the policy directs states/territories with no LCD/LCA to refer to corresponding UnitedHealthcare Commercial Medical Policies (e.g., QST codes 0106T-0110T, 0464T, 0627T-0630T).

Applies when no local CMS guidance is found.

Per-code coverage conclusions

UnitedHealthcare Medicare Advantage conclusions for listed Category III CPT codes

0638T: Conclusion = Not Reasonable and Necessary; refer to the UnitedHealthcare Commercial Medical Policy titled Breast Imaging for Screening and Diagnosing.

CMS NCD Coverage Criteria = No; CMS LCD/LCA Coverage Criteria = No

0646T: Conclusion = Refer to NCD.

CMS NCD Coverage Criteria = NCD for Transcatheter Tricuspid Valve Replacement (TTVR) (NCD 20.37); CMS LCD/LCA Coverage Criteria = No

0655T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions.

CMS NCD = No; CMS LCD/LCA = No

0687T/0688T/0704T/0705T/0706T:

This policy addresses a large number of American Medical Association Category III CPT codes that track emerging technologies, services, and procedures. UnitedHealthcare Medicare Advantage concludes that many of these Category III codes are Not Reasonable and Necessary for Medicare Advantage coverage and therefore are excluded from coverage. Where the policy finds services Not Reasonable and Necessary it directs providers to the named UnitedHealthcare Commercial Medical Policy that most closely relates to the service for additional guidance (examples across the list include codes directing readers to policies such as Autologous Cellular Therapy, Transcatheter Procedures for Heart Valve Conditions, Extracorporeal Shock Wave Therapy (ESWT), and Breast Imaging for Screening and Diagnosing).

In addition to the broad exclusions above, the policy provides per-code conclusions for numerous Category III T-codes. Several codes are explicitly concluded Not Reasonable and Necessary and the document redirects readers to the specified UnitedHealthcare commercial medical policies for clinical or billing details (for example, 0638T to the Breast Imaging policy; 0655T and multiple prostate-related codes to the Prostate Surgeries and Interventions policy; 0687T–0706T to Visual Information Processing/Orthoptic policy). Other T-codes are referred to applicable CMS National Coverage Determinations (NCDs) and must follow that NCD (examples include TTVR/TTVI codes such as 0646T — NCD 20.37 — and the cluster of leadless pacemaker codes referred to the Leadless Pacemakers NCD 20.8.4).

This policy revision includes an update to the listed CPT codes. As part of the 04/01/2026 changes, the policy removed language and content referencing anterior lumbar and thoracolumbar vertebral body tethering (CPT codes 0656T and 0657T) and the revision/replacement/removal of thoracolumbar or lumbar vertebral body tethering (CPT code 0790T). See Policy History/Revision Information for the summary of this change.

Throughout the document multiple specific Category III codes are explicitly concluded Not Reasonable and Necessary. Examples called out in this portion of the policy include (but are not limited to) 0202T, 0263T–0265T, 0278T, 0342T, 0483T–0484T, 0489T–0490T, 0505T, 0512T–0513T, 0566T, 0582T, 0598T–0599T, 0619T, 0627T–0630T, 0633T–0638T, 0655T, 0687T–0706T, 0693T, 0717T–0719T, 0720T, 0737T–0739T, 0744T, 0778T–0779T, 0783T, 0805T–0806T, 0813T–0814T, 0858T, 0864T, 0867T–0868T, 0889T–0892T, 0902T, and 0999T–1001T. For each code the policy indicates the related UnitedHealthcare Commercial Medical Policy to consult for clinical detail and billing guidance where coverage is deemed Not Reasonable and Necessary.

Numerous Category III T-codes throughout this segment are labeled Not Reasonable and Necessary or are specifically referred to CMS NCDs. Notable groupings include the leadless pacemaker series (e.g., 0795T–0826T, 0804T) which are linked to the CMS NCD for Leadless Pacemakers (NCD 20.8.4) and therefore must follow that NCD for Medicare coverage determinations. Other T-code referrals to NCDs include codes such as 0646T (TTVR/TTVI — NCD 20.37) and 0736T (Colonic Irrigation — NCD 100.7). Where an NCD applies, the NCD governs coverage rather than this policy.

CPT / Category III Coding Details

QST Category III CodesCPT

0106T	Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation.
0107T	Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation.
0108T	Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia.
0109T	Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia.
0110T	Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation.

Selected Procedure CodesCPT

0202T	Posterior vertebral joint(s) arthroplasty (e.g., facet joint(s) replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation...
0238T	Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and...
0278T	Transcutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes).

Various Category III Codes and DescriptionsCPT

0342T	Therapeutic apheresis with selective HDL delipidation and plasma reinfusion.
0422T	Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral.
0464T	Visual evoked potential, testing for glaucoma, with interpretation and report.
0483T	Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach...
0484T	Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (e.g., thoracotomy, transapical).
0489T	Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation...
0490T	Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands.
0505T	Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure...
0512T	Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial wound.
0513T	Extracorporeal shock wave for integumentary wound healing; each additional wound.

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Category III codes (segment start)CPT

0638T	Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s).
0646T	Transcatheter tricuspid valve implantation/replacement (TTVI) with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed.
0655T	Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging.
0687T	Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session.
0688T	Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month.

Category III codes (continued)CPT

0693T	Comprehensive full body computer-based markerless 3D kinematic and kinetic motion analysis and report.
0704T	Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment.
0705T	Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days.
0706T	Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month.
0714T	Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume less than 50 mL.
0717T	Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs.
0718T	Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral.
0719T	Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment.
0720T	Percutaneous electrical nerve field stimulation, cranial nerves, without implantation (Deleted 12/31/2025 - See 64567).
0736T	Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter.

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CPT codes referenced in revisionCPT

0656T	Anterior lumbar vertebral body tethering (removed from policy content)
0657T	Anterior thoracolumbar vertebral body tethering (removed from policy content)
0790T	Revision, replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy (removed from policy content)

General coding guidancemixed

No codes listed

Deletion date reference — 0564T

Code0564T

StatusDeleted 12/31/2024

NotesSee 89240; Refer to NCD for Human Tumor Stem Cell Drug Sensitivity Assays (190.7) and applicable LCDs

Deletion date reference — 0619T

Code0619T

StatusDeleted 12/31/2025

Provider Responsibilities, Prior Authorization, and Billing Guidance

Prior Authorization

Confirm Medicare NCD/LCD/LCA; then follow UnitedHealthcare policy

Providers must confirm whether a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or Local Coverage Article (LCA) applies to the requested service or code by searching the Medicare Coverage Database. If an applicable NCD/LCD/LCA exists, follow that Medicare determination. If no Medicare coverage guidance exists, follow the UnitedHealthcare Medicare Advantage Medical Policy guidance referenced in this document.

Search the Medicare Coverage Database before relying on this UHC policy.
When an NCD/LCD/LCA exists, Medicare contractor guidance supersedes UHC policy for Medicare Advantage members.

Prior Authorization

Delegate-managed prior authorization

For Medicare Advantage members whose utilization management and prior authorization are managed by a delegated organization, follow the delegate's prior authorization requirements and processes in addition to any UnitedHealthcare policy requirements.

Delegate-managed prior authorization requirements take precedence for submission and authorization workflows.

Background and Context

Category III codes are temporary CPT codes the AMA issues to track emerging services; their presence alone does not establish coverage or clinical appropriateness. This policy documents that many Category III codes are concluded Not Reasonable and Necessary for UnitedHealthcare Medicare Advantage and either exclude those codes from coverage or redirect coverage determinations to applicable UnitedHealthcare Commercial Medical Policies or CMS National Coverage Determinations. Providers should confirm applicable NCD/LCD/LCA guidance and follow the referenced UnitedHealthcare policy when no Medicare contractor determination exists.

Definitions and Legal Standards

Category III CPT codes

DefinitionTemporary CPT codes developed by the AMA to track utilization of emerging technologies, services, and procedures; their presence does not establish clinical safety, effectiveness, or coverage.

PurposeTrack emerging services and procedures for data collection and reporting.

Coverage implicationAssignment of a Category III code does not imply the service is reasonable and necessary for payment under Medicare.

Reasonable and Necessary (SSA 1862(a)(1)(A))

DefinitionCoverage standard requiring items and services be consistent with the diagnosis, necessary and consistent with generally accepted professional medical standards (SSA 1862(a)(1)(A)).

Criteria examplesMust be safe and effective, consistent with symptoms/diagnosis, not primarily for convenience, furnished at appropriate level/duration/setting.

Policy Summary

PayerUnitedHealthcare

PolicyCategory III CPT Codes

Policy CodePolicy MMP043.47

Change TypeRevised CPT listremoved tethering codes

Effective DateApr 1, 2026

Next Review DateN/A

SourceLink

On This Page

Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Visual Information Processing Evaluation and Orthoptic and Vision Therapy.

CMS NCD = No; CMS LCD/LCA = No

0693T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Diagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis.

CMS NCD = No; CMS LCD/LCA = No

0717T/0718T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Autologous Cellular Therapy.

CMS NCD = No; CMS LCD/LCA = No

0719T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Decompression.

CMS NCD = No; CMS LCD/LCA = No

0720T/0783T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.

CMS NCD = No; CMS LCD/LCA = No

0736T: Conclusion = Refer to NCD.

CMS NCD Coverage Criteria = NCD for Colonic Irrigation (100.7); CMS LCD/LCA = No

0737T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Surgery of the Knee.

CMS NCD = No; CMS LCD/LCA = No

0738T/0739T/0744T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions (0738T/0739T) and Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (0744T).

CMS NCD = No; CMS LCD/LCA = No

0778T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Neurophysiologic Testing and Monitoring.

CMS NCD = No; CMS LCD/LCA = No

0779T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Gastrointestinal Disorders Diagnostic Procedures.

CMS NCD = No; CMS LCD/LCA = No

0795T-0826T (leadless pacemaker codes): Conclusion = Refer to NCD.

CMS NCD Coverage Criteria = NCD for Leadless Pacemakers (20.8.4); CMS LCD/LCA = No

0805T/0806T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Transcatheter Procedures for Heart Valve.

CMS NCD = No; CMS LCD/LCA = No

0813T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Bariatric Surgery.

CMS NCD = No; CMS LCD/LCA = No

0814T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Spinal Fusion and Bone Healing Enhancement Products.

CMS NCD = No; CMS LCD/LCA = No

0858T/0889T-0892T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Transcranial Magnetic Stimulation for Treating Physical Health Conditions.

CMS NCD = No; CMS LCD/LCA = No

0864T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications.

CMS NCD = No; CMS LCD/LCA = No

0902T: Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Implantable Loop Recorders and Wearable Heart Rhythm Monitors.

CMS NCD = No; CMS LCD/LCA = No

0999T/1000T/1001T: Conclusions = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Autologous Cellular Therapy.

CMS NCD = No; CMS LCD/LCA = No

NotesSee 52443; Conclusion = Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions.

Prostate volume threshold — 0714T / 0867T

0714T thresholdProstate volume less than 50 mL

0867T thresholdProstate volume greater or equal to 50 mL

Coverage stanceBoth codes concluded Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions.

Denial Risk

0638T denial risk

Claims submitted with CPT Category III code 0638T are concluded Not Reasonable and Necessary by UnitedHealthcare Medicare Advantage. Providers should expect denials and should refer to the UnitedHealthcare Commercial Medical Policy referenced for breast imaging screening and diagnosis.

0638T — Expected denial as Not Reasonable and Necessary; see related UHC commercial policy.

Denial Risk

Leadless pacemaker T-code denial risk and NCD referral

Multiple Category III T-codes for leadless pacemaker procedures are subject to CMS National Coverage Determination 20.8.4 (Leadless Pacemakers). When CMS NCD 20.8.4 applies, refer to the NCD for coverage criteria and adjudication; claims may be denied or require NCD-based review.

Affected codes include (not limited to): 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0823T, 0824T.
If NCD 20.8.4 applies, follow NCD adjudication and documentation requirements; UHC will refer to the NCD.

Note

Search Medicare Coverage Database and reference UHC policy when no Medicare guidance exists

After searching the Medicare Coverage Database, if no NCD/LCD/LCA is found for the code or service, follow the UnitedHealthcare Medicare Advantage Medical Policy coverage rationale and code-specific conclusions included in this policy document.

Use the UHC policy table and related commercial policies referenced when Medicare coverage guidance is absent.

Note

CMS/MAC documentation and contractor guidance

Refer to the listed Medicare Administrative Contractors (MACs) and CMS documents for contractor-specific guidance, billing instructions, and coverage articles relevant to the member's jurisdiction when preparing claims and supporting documentation.

MACs referenced: CGS, First Coast, NGS, Noridian, Novitas, Palmetto, WPS — confirm the member's MAC based on state/territory.
Consult MAC-specific guidance when an LCD/LCA exists or for local billing rules.

Documentation Required

Documentation retention expectations

Providers are expected to retain or have access to appropriate documentation to support coverage determinations. UnitedHealthcare may request supporting records to validate that services met coverage criteria and medical necessity; failure to produce required documentation may result in denial, recoupment, or adverse coverage determination.

Retain clinical records, operative notes, device information (including FDA status), imaging, and prior authorization approvals as applicable.
Documentation retention expectations apply to Medicare Advantage adjudications.

Billing Rule

Coding and accurate claims submission

Use CPT, CMS, and other recognized coding guidelines when submitting claims. References to coding systems in this policy are definitional and do not guarantee payment. Accurate coding and claim submission are the provider's responsibility; incorrect coding may lead to claim denial.

Follow CPT, CMS, and MAC coding guidance; include appropriate modifiers and device identifiers where required.
References in this policy do not imply coverage—confirm coverage via NCD/LCD/LCA or UHC policy conclusions.

Denial basisServices that are experimental, not generally accepted, or not reasonable and necessary may be denied under SSA 1862(a)(1)(A).

Title XVIII, Section 1862(a)(1)(A) of the Social Security Act

ReferenceTitle XVIII, Section 1862(a)(1)(A) of the Social Security Act

Short descriptionMedically Reasonable & Necessary standard used to determine Medicare payment eligibility.

Source guidanceReferenced in Medicare Managed Care Manual and policy definitions for coverage determinations.

L35490 Category III Codes A56902 Billing and Coding: Category III Codes

Reference IDL35490 / A56902

TopicCategory III Codes — Billing and Coding guidance

PurposeProvides definitional and coding references for Category III CPT codes; references do not guarantee payment.