ModifiedUnitedHealthcarePolicy EXPERIMENTAL 004.13

CPT Category III Codes (experimental services)

Lists CPT Category III (temporary/experimental) procedure codes and states these services are generally considered experimental, investigational, or unproven and not medically necessary unless addressed in another UnitedHealthcare policy; applies to UnitedHealthcare/Oxford members per benefit documents.

Policy Summary

PayerUnitedHealthcare

PolicyCPT Category III Codes (experimental services)

Policy CodePolicy EXPERIMENTAL 004.13

Change TypeApplicable Codes added/updated

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionCheck member-specific benefit plan documents and applicable mandates before assuming coverage for services represented by Category III CPT codes.

SourceLink

POLICY UPDATE CHANGES

Multiple Category III CPT codes (0956T–0960T, 0962T–0976T, 0977T–0983T, and others) were added to the Applicable Codes list.

Explanation of Category III codes' purpose and archival timeframe (generally archived five years from publication) was provided.

100+Category III CPT codes listed (approximate count)

07/01/2025Policy effective date

5 yrsArchival period (AMA)

07/01/2025Revision date for Applicable Codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Category III CPT Codes

Coverage stance for Category III codes

General coverage stance for CPT Category III codes:

Services represented by CPT Category III codes are generally considered experimental, investigational, or unproven and not medically necessary due to insufficient evidence of efficacy unless specifically addressed in another UnitedHealthcare Policy.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service; inclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Other UnitedHealthcare policies and guidelines may apply; inclusion of a Category III code in this document does not guarantee reimbursement or payment and does not override member-specific benefit plan documents.

Coverage exclusion for experimental/unproven services

Coverage exclusions and plan governance:

Services that are not medically necessary, experimental, investigational, or unproven are excluded from coverage on most plans.

The fact that a service is the only available treatment for a condition does not change the exclusion if the service is considered not medically necessary, experimental, investigational, or unproven.

This exclusion does not apply to certain covered health care services provided during a clinical trial when benefits are provided under the member's benefit plan document.

When deciding coverage, the member-specific benefit plan document and any applicable federal or state mandates must be referenced; in the event of a conflict, the member-specific benefit plan document governs.

Category III CPT Codes (Representative Listings)

Sample listed Category III codes (document contains many more)CPTExperimental

0419T	Destruction of neurofibroma; extensive (cutaneous, dermal extending into subcutaneous); face, head and neck; greater than 50 neurofibromas.
0420T	Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas.
0524T	Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring.
0541T	Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study.
0542T	Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia; interpretation and report; single study.

Additional Category III codes (excerpts)CPTExperimental

0554T	Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report.
0587T	Percutaneous implantation or replacement of integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator; including analysis, programming; and imaging guidance when performed, posterior tibial nerve.
0602T	Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent.
0606T	Optical coherence tomography (OCT) of retina, remote; review; interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days.

Selected Category III codes listed in this policy excerptCPTExperimental

0931T	Electrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation-defibrillator pulse generator.
0933T	Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment; right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation.
0934T	Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional.
0946T	Orthopedic implant movement analysis paired computed tomography (CT) examination of the target structure, including data acquisition, data preparation and transmission, interpretation and report (including CT scan of the joint or extremity performed with paired views).
0956T	Partial 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.
0957T	Revision of sub-scalp implanted electrode array, receiver; and telemetry unit for electrode, when required, including imaging guidance.
0958T	Removal of sub-scalp implanted electrode array, receiver; and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance.
0959T	Removal or replacement of magnet from coil assembly that is connected to continuous bilateral electroencephalography monitoring system, including imaging guidance.
0960T	Replacement of sub-scalp implanted electrode receiver, and telemetry unit with tunneling of electrode for continuous bilateral electroencephalography monitoring system, including imaging guidance.
0962T	Assistive algorithmic analysis of acoustic and electrocardiogram recording for detection of cardiac dysfunction (e.g., reduced ejection fraction, cardiac murmurs, atrial fibrillation), with review and interpretation by a physician or other qualified health care professional.

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Listing purpose

Purpose of listingCodes are provided for reference only; listing of a code does not imply that the service described by the code is a covered or non‑covered health service.

No guarantee of paymentInclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Benefit determinationBenefit coverage is determined by the member‑specific benefit plan document and applicable laws that may require coverage for a specific service.

Not all‑inclusiveThe listed procedures and diagnosis codes are provided for reference purposes only and may not be all inclusive.

Other policies may applyOther Policies and Guidelines may apply when evaluating coverage and reimbursement.

Definitions and Code Purpose

Temporary codes (Category III) — definition and implications

Definition (Category III codes)Temporary codes for emerging technologies, services, and procedures; often considered experimental, investigational, or unproven for coverage purposes.

Data collection purposeCategory III codes allow identification and data collection for emerging technologies and procedures, offering an alternative to unlisted codes.

FDA approval not requiredCategory III CPT codes do not require U.S. Food and Drug Administration (FDA) approval for assignment to the category.

Inclusion ≠ endorsementPer the AMA, inclusion of a service or procedure as a Category III code does not constitute a finding of support or lack thereof regarding clinical efficacy, safety, applicability to clinical practice, or payer coverage.

Archival timeframeGenerally archived five years from the date of initial publication unless the archival date is modified at the time of a revision.

Provider Actions and Utilization Management

Denial Risk

Category III codes generally considered experimental — may be noncovered

Procedures, services, or items represented by CPT Category III codes are generally considered experimental, investigational, or unproven and are not medically necessary due to insufficient evidence of efficacy unless specifically addressed in another UnitedHealthcare policy. This status may lead to denial of coverage or require that an alternate UnitedHealthcare policy authorizes the service.

Listing of a Category III code does not by itself imply the service is covered or payable.

Documentation Required

Verify member benefits and applicable mandates; plan governs conflicts

Verify the member-specific benefit plan document and any applicable federal or state mandates before determining coverage; when there is a conflict, the member-specific plan document governs.

Check member-specific benefits as plan terms may differ from standard plans.