Category III CPT Codes

Coverage Summary

This policy provides UnitedHealthcare Medicare Advantage guidance for AMA Category III CPT codes when there is no applicable Medicare NCD, LCD, or LCA and no specific UnitedHealthcare Medicare Advantage policy addressing the code. It lists individual Category III codes with descriptions, indicates whether a CMS NCD/LCD/LCA applies, and gives a coverage conclusion or direction to a referenced UnitedHealthcare Commercial Medical Policy to support coverage determinations for Medicare Advantage members.

Policy metadata and dates

Effective DateApril 1, 2026

Last ReviewMarch 11, 2026

Next Review

Policy NumberMMP043.47

StatusCURRENT

Scope SummaryUnitedHealthcare Medicare Advantage guidance for coverage conclusions for AMA Category III CPT codes when no applicable Medicare NCD/LCD/LCA or specific UnitedHealthcare policy exists; lists individual Category III codes with descriptions, CMS NCD/LCD/LCA coverage criteria presence, and a coverage conclusion or referral to another UHC policy.

Medical-Necessity Criteria

General Coverage Rationale

Policy applies when no Medicare coverage guideline or UnitedHealthcare policy specifically addresses a Category III CPT code;

Steps to determine applicable coverage guidance: Search the Medicare Coverage Database to confirm no applicable Medicare NCD/LCD/LCA exists
If no Medicare guidance found: Search for a UnitedHealthcare Medicare Advantage Medical Policy that specifically addresses the service/code
If neither Medicare nor UHC policy found: Refer to the table in this policy for coverage conclusion per Category III code

Coverage Conclusions for Listed Category III Codes

Coding

Category III codes listed with 'Conclusion = Not Reasonable and Necessary' (refer to named UnitedHealthcare Commercial Medical Policy)CPTNot Covered

0202T	Posterior vertebral joint(s) arthroplasty; Conclusion: Not Reasonable and Necessary; refer to Spinal Fusion and Decompression.
0238T	Transluminal peripheral atherectomy; Conclusion: Not Reasonable and Necessary; refer to Lower Extremity Endovascular Procedures.
0263T	Intramuscular autologous bone marrow cell therapy; Conclusion: Not Reasonable and Necessary; refer to Autologous Cellular Therapy.
0264T	Intramuscular autologous bone marrow cell therapy excluding bone marrow harvest; Conclusion: Not Reasonable and Necessary; refer to Autologous Cellular Therapy.
0265T	Bone marrow harvest only; Conclusion: Not Reasonable and Necessary; refer to Autologous Cellular Therapy.
0278T	Transcutaneous electrical modulation pain reprocessing (scrambler therapy); Conclusion: Not Reasonable and Necessary; refer to Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.
0342T	Therapeutic apheresis with selective HDL delipidation; Conclusion: Not Reasonable and Necessary; refer to Apheresis.
0422T	Tactile breast imaging by computer-aided tactile sensors; Conclusion: Not Reasonable and Necessary; refer to Breast Imaging for Screening and Diagnosing Cancer.
0483T	Transcatheter mitral valve implantation/replacement (percutaneous); Conclusion: Not Reasonable and Necessary; refer to Transcatheter Procedures for Heart Valve Conditions.
0484T	Transcatheter mitral valve implantation/replacement (transthoracic exposure); Conclusion: Not Reasonable and Necessary; refer to Transcatheter Procedures for Heart Valve Conditions.

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Category III codes with 'Conclusion = Refer to NCD' (National Coverage Determination applies)CPT

0564T	Oncology chemotherapeutic drug cytotoxicity assay of cancer stem cells; CMS NCD for Human Tumor Stem Cell Drug Sensitivity Assays (190.7); Conclusion: Refer to NCD and/or LCD.
0569T	Transcatheter tricuspid valve repair initial prosthesis; CMS NCD for T-TEER (20.38); Conclusion: Refer to NCD.
0570T	Each additional prosthesis for transcatheter tricuspid valve repair; CMS NCD for T-TEER (20.38); Conclusion: Refer to NCD.
0646T	Transcatheter tricuspid valve implantation/replacement (TTVI) prosthetic valve; CMS NCD for TTVR (NCD 20.37); Conclusion: Refer to NCD.
0736T	Colonic lavage ≥35L; CMS NCD for Colonic Irrigation (100.7); Conclusion: Refer to NCD.
0795T	Transcatheter insertion permanent dual-chamber leadless pacemaker complete system; CMS NCD for Leadless Pacemakers (20.8.4); Conclusion: Refer to NCD.
0796T	Transcatheter insertion dual-chamber leadless pacemaker right atrial component; CMS NCD for Leadless Pacemakers (20.8.4); Conclusion: Refer to NCD.
0797T	Transcatheter insertion dual-chamber leadless pacemaker right ventricular component; CMS NCD for Leadless Pacemakers (20.8.4); Conclusion: Refer to NCD.
0798T	Transcatheter removal permanent dual-chamber leadless pacemaker complete system; CMS NCD for Leadless Pacemakers (20.8.4); Conclusion: Refer to NCD.
0799T	Transcatheter removal permanent dual-chamber leadless pacemaker right atrial component; CMS NCD for Leadless Pacemakers (20.8.4); Conclusion: Refer to NCD.

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Category III codes with CMS LCD/LCA references (coverage guidance by referenced LCD/LCA or referral to another UHC policy)CPT

0106T	QST touch pressure per extremity; CMS LCD/LCA: First Coast L34859 (A57123), Novitas L35081 (A54095); Conclusion: For states/territories with no LCDs/LCAs, refer to UHC Commercial Medical Policy titled Neurophysiologic Testing.
0107T	QST vibration per extremity; CMS LCD/LCA: First Coast L34859 (A57123), Novitas L35081 (A54095); Conclusion: refer to Neurophysiologic Testing and Monitoring.
0108T	QST cooling stimuli per extremity; CMS LCD/LCA: First Coast L34859 (A57123), Novitas L35081 (A54095); Conclusion: refer to Neurophysiologic Testing and Monitoring.
0109T	QST heat-pain per extremity; CMS LCD/LCA: First Coast L34859 (A57123), Novitas L35081 (A54095); Conclusion: refer to Neurophysiologic Testing and Monitoring.
0110T	QST other stimuli per extremity; CMS LCD/LCA: First Coast L34859 (A57123), Novitas L35081 (A54095); Conclusion: refer to Neurophysiologic Testing and Monitoring.
0464T	Visual evoked potential testing for glaucoma; CMS LCD/LCA: NGS L36831 (A57060); Conclusion: For states/territories with no LCDs/LCAs, refer to Neurophysiologic Testing.
0627T	Percutaneous injection allogeneic cellular product intervertebral disc lumbar first level; CMS LCD/LCA: CGS L39958 (A59880), Noridian L39960 (A59882), Noridian L39962 (A59884), Palmetto L39942; Conclusion: refer to Discogenic Pain Treatment.
0628T	Percutaneous injection additional level; same LCD/LCA references as 0627T; Conclusion: refer to Discogenic Pain Treatment.
0629T	Percutaneous injection with CT guidance first level; same LCD/LCA references; Conclusion: refer to Discogenic Pain Treatment.
0630T	Percutaneous injection with CT guidance additional level; same LCD/LCA references; Conclusion: refer to Discogenic Pain Treatment.

Category III CPT Codes Listed with ConclusionsCPT

0825T	Refer to NCD; Conclusion listed as 'Refer to NCD' in document part.
0826T	Programming device evaluation ... leadless pacemaker system; Refer to NCD (NCD for Leadless Pacemakers 20.8.4).
0858T	Externally applied transcranial magnetic stimulation with concomitant measurement of evoked cortical potentials with automated report; Not Reasonable and Necessary.
0864T	Low-intensity extracorporeal shock wave therapy for corpus cavernosum; Not Reasonable and Necessary.
0867T	Transperineal laser ablation of BPH, prostate volume >= 50 mL; Not Reasonable and Necessary.
0868T	High-resolution gastric electrophysiology mapping with symptom profiling; Not Reasonable and Necessary.
0889T	Personalized target development for MRI-guided theta-burst stimulation; Not Reasonable and Necessary.
0890T	Accelerated MRI-guided theta-burst stimulation, initial day; Not Reasonable and Necessary.
0891T	Accelerated MRI-guided theta-burst stimulation, subsequent day; Not Reasonable and Necessary.
0892T	MRI-guided theta-burst stimulation subsequent motor threshold redetermination; Not Reasonable and Necessary.

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Provider Actions

Documentation Required

Search Medicare Coverage Database and UHC policies

Providers must search the Medicare Coverage Database for applicable NCDs/LCDs/LCAs and then search UnitedHealthcare Medicare Advantage Medical Policies. If no Medicare coverage guideline or UHC Medicare Advantage policy specifically addresses the Category III CPT code, use the conclusions in this policy's Category III CPT code table to determine coverage or referral. Actionable bullets: - Search the Medicare Coverage Database for applicable NCD/LCD/LCA. - If no Medicare guidance found, search UnitedHealthcare Medicare Advantage Medical Policies for the service/code. - If none apply, refer to the Category III CPT code table in this policy for the coverage conclusion or referral.

Search Medicare Coverage Database for applicable NCD/LCD/LCA
If none found, search UnitedHealthcare Medicare Advantage Medical Policies
If still none, use this policy's Category III CPT code table for coverage conclusions

Documentation Required

Background

Category III CPT codes are temporary codes created by the AMA to track emerging technologies, services, and procedures; the code description does not by itself establish that a service is safe, effective, or medically necessary. Under Section 1862(a)(1)(A) of the Social Security Act (SSA), items and services not established as safe and effective or otherwise reasonable and necessary may be denied payment. Medical devices not approved for FDA marketing are considered investigational and Medicare payment generally is not made for procedures using such devices unless performed in an approved FDA Investigational Device Exemption (IDE) trial.

Definitions

Medicare Determinations

Revision History

04/01/2026revised (material)Latest

Revised list of applicable CPT codes and removed content/language addressing specific Category III codes for vertebral body tethering (removed mention of CPT codes 0656T, 0657T, and 0790T).

updated (administrative)

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

archived (administrative)

Archived previous policy version MMP043.46.

Per-code Coverage Conclusions

Each CPT Category III code entry includes CMS NCD/LCD coverage criteria (Yes/No) and a UnitedHealthcare conclusion.

0825T — Transcatheter removal and replacement of permanent single‑chamber leadless pacemaker, right atrial; CMS NCD Coverage Criteria: NCD for Leadless Pacemakers (20.8.4); CMS LCD/LCA Coverage Criteria: No; Conclusion: Refer to NCD
0826T — Programming device evaluation (in person) with iterative adjustment for leadless pacemaker system; CMS NCD Coverage Criteria: NCD for Leadless Pacemakers (20.8.4); CMS LCD/LCA Coverage Criteria: No; Conclusion: Refer to NCD
0858T — Externally applied transcranial magnetic stimulation with measurement of evoked cortical potentials; CMS NCD Coverage Criteria: No; CMS LCD/LCA Coverage Criteria: No; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Transcranial Magnetic Stimulation for Treating Physical Health Conditions'.
0864T — Low‑intensity extracorporeal shock wave therapy for corpus cavernosum; CMS NCD Coverage Criteria: No; CMS LCD/LCA Coverage Criteria: No; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications'.
0867T — Transperineal laser ablation of BPH, prostate volume ≥50 mL; CMS NCD Coverage Criteria: No; CMS LCD/LCA Coverage Criteria: No; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Prostate Surgeries and Interventions'.
0868T — High‑resolution gastric electrophysiology mapping with symptom profiling; CMS NCD Coverage Criteria: No; CMS LCD/LCA Coverage Criteria: No; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Gastrointestinal Disorders Diagnostic Procedures'.
0889T-0892T: 0889T–0892T — MRI‑guided theta‑burst stimulation series (personalized target development and accelerated treatment codes); CMS NCD Coverage Criteria: No for each; CMS LCD/LCA Coverage Criteria: No for each; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Transcranial Magnetic Stimulation for Treating Physical Health Conditions'.
0902T — QTc interval derived by algorithmic analysis from mobile ECG device; CMS NCD Coverage Criteria: No; CMS LCD/LCA Coverage Criteria: No; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Implantable Loop Recorders and Wearable Heart Rhythm Monitors'.
0999T-1001T: 0999T–1001T — Autologous muscle cell therapy series (harvest, urethral administration, anal sphincter injection); CMS NCD Coverage Criteria: No for each; CMS LCD/LCA Coverage Criteria: No for each; Conclusion: Not Reasonable and Necessary; refer to UnitedHealthcare Commercial Medical Policy ‘Autologous Cellular Therapy'.