*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + MedicareSM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure or Service

CPT Category III codes are a set of temporary codes that allow data collection for emerging technologies, services, and procedures. These codes are intended to be used for data collection to substantiate widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. CPT Category III codes are not required to conform to the CPT Category I code requirements. Devices to perform the procedure or service may not have FDA clearance or approval, the procedure or service may not be performed by many health care professionals across the country, the procedure or service may not be performed with a frequency that is consistent with the intended clinical use, the procedure or service may not be consistent with current medical practice, and the clinical efficacy of the procedure or service may not be proven.1 The codes are a five-character alphanumeric string, with numbers

and the letter “T” as the fifth character (e.g., 0307T). They are not intended to indicate that a service is clinically effective, safe, or established as a standard of care.

Policy Statement

This policy provides a listing of American Medical Association (AMA) Category III CPT^® codes, which are reviewed and updated on a quarterly basis in accordance with AMA publications. The policy serves as an administrative reference and does not establish or include clinical coverage criteria, medical necessity requirements, or utilization management guidelines.

Coverage determinations for services represented by Category III CPT^® codes are subject to applicable member benefits, and any relevant medical policies that are in the member's benefit plan and coverage terms.

The absence of a code from this policy does not imply coverage. Please refer to the applicable coverage criteria (NCD, LCD, MCG, internal medical policy) to determine coverage for a specific procedure.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan.  If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

Indications for Coverage

Before utilizing this policy verify if there is an applicable NCD, LCD or MCG Guideline for the Category III code(s) received for medical necessity review. If no applicable NCD, LCD or MCG Guideline is available please proceed with this policy. CPT Category III codes are assigned for data collection purposes. Services, items, or procedures billed with Category III codes are considered experimental, investigational, or unproven unless coverage is specifically addressed in an applicable NCD, LCD, Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare^SM (HMO-POS D-SNP) Coverage Policy.

When Coverage Will Not Be Approved

The use of a service, procedure or supply that is not recognized as standard medical care for the condition, disease, illness, or injury being treated is considered an experimental/investigational service. Coverage may be allowed when such services are performed as part of a more comprehensive covered service or when required under a provider contract. CPT Category III codes are not covered unless coverage is explicitly provided by an applicable NCD, LCD, or Medicare Advantage Coverage Policy (e.g., Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare^SM (HMO-POS D-SNP)).

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

0071T, 0072T, 0075T, 0076T, 0100T, 0101T, 0102T, 0175T, 0198T, 0202T, 0207T, 0208T, 0209T, 0210T, 0211T, 0212T, 0219T, 0220T, 0221T, 0222T, 0232T, 0253T, 0263T, 0264T, 0265T, 0274T, 0278T, 0329T, 0330T, 0331T, 0332T, 0333T, 0338T, 0339T, 0342T, 0345T, 0348T, 0349T, 0350T, 0351T, 0352T, 0353T, 0354T, 0358T, 0362T, 0373T, 0395T, 0397T, 0402T, 0408T, 0409T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0419T, 0420T, 0450T, 0479T, 0480T, 0483T, 0485T, 0489T, 0490T, 0494T, 0495T, 0496T, 0506T, 0507T, 0509T, 0510T, 0511T, 0512T, 0513T, 0515T, 0516T, 0518T, 0519T, 0520T, 0521T, 0522T, 0525T, 0526T, 0527T, 0528T, 0530T, 0531T, 0532T, 0541T, 0542T, 0543T, 0544T, 0545T, 0546T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T, 0561T, 0562T, 0563T, 0565T, 0566T, 0569T, 0570T, 0575T, 0576T, 0577T, 0578T, 0579T, 0581T, 0582T, 0583T, 0587T, 0588T, 0589T, 0590T, 0591T, 0592T, 0593T, 0594T, 0607T, 0608T, 0621T, 0622T, 0632T, 0639T, 0640T, 0643T, 0645T, 0646T, 0647T, 0650T, 0651T, 0652T, 0653T, 0654T, 0655T, 0656T, 0657T, 0658T, 0659T, 0660T, 0661T, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T, 0671T, 0672T, 0673T, 0674T, 0675T, 0677T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0686T, 0687T, 0688T, 0689T, 0691T, 0692T, 0693T, 0694T, 0695T, 0696T, 0697T, 0699T, 0700T, 0704T, 0705T, 0706T, 0708T, 0710T, 0711T, 0712T, 0714T, 0716T, 0717T, 0718T, 0719T, 0721T, 0723T, 0724T, 0725T, 0727T, 0728T, 0729T, 0730T, 0731T, 0732T, 0733T, 0734T, 0735T, 0736T, 0737T, 0738T, 0739T, 0742T, 0743T, 0744T, 0745T, 0746T, 0747T, 0748T, 0749T, 0750T, 0751T, 0752T, 0753T, 0754T, 0755T, 0756T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T, 0763T, 0764T, 0765T, 0766T, 0767T, 0770T, 0771T, 0772T, 0773T, 0774T, 0776T, 0777T, 0778T, 0779T, 0781T, 0782T, 0783T, 0784T, 0785T, 0786T, 0787T, 0790T, 0791T, 0792T, 0793T, 0794T, 0804T, 0805T, 0806T, 0807T, 0808T, 0810T, 0811T, 0812T, 0813T, 0814T, 0815T, 0826T, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 0857T, 0864T

The Centers for Medicare & Medicaid Services (CMS) actively maintains edits—including Procedure-to-Procedure (PTP) and Medically Unlikely Edits (MUEs)—for many Category III codes. The standard coding and bundling policies are applied to Category III codes are the same as those used for standard Category I CPT

These codes are subject to change and additional codes may be added when CMS updates are received. Because of the specific purpose CPT^® Category III codes serve, unless there is another medical policy or Utilization Management (UM) delegate medical policy or guideline that 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 as per this policy.

Related Policies

Add-On Codes

Bundling Guidelines

Investigational (Experimental) Services

Maximum Units of Service

NCCI Editing

Status Codes

Special Notes

Inclusionary and Exclusionary Guidelines

1. Governmental approval of a service is considered in determining whether a service is experimental or investigational. However, governmental approval does not necessarily mean that the service has proven benefit or is an appropriate or effective treatment for a diagnosis or for a particular condition.
2. In assessing whether there is rigorous scientific evidence to determine if a service is or is not experimental or investigational, the following five criteria must be met:
   1. A service that is a medical device, drug, or biological product must have received final approval from the appropriate government regulatory bodies (e.g., the United States Food and Drug Administration [FDA]). Any other approval granted as an interim step in the regulatory process (e.g., an Investigational Device Exemption or an Investigational New Drug Exemption) is not sufficient.
   2. Published, peer-reviewed medical literature must provide evidence that the service has a definite, positive effect on health outcomes. The evidence must include reports of well-designed investigations that have been reproduced by nonaffiliated, authoritative sources with measurable results, supported by the positive endorsements of national medical bodies or panels.
   3. Published, peer-reviewed medical literature must provide evidence that, over time, the service leads to improvement in health outcomes (e.g., the beneficial effects of the service outweigh any harmful effects).
   4. Published, peer-reviewed medical literature must provide evidence that the service is at least as effective in improving health outcomes as established services or technologies, or is appropriate in clinical contexts in which an established service or technology is not employable.
   5. Published, peer-reviewed medical literature must provide evidence that improvement in health outcomes is possible in standard conditions of medical practice, outside of clinical investigatory settings.

References

1. American Medical Association. CPT^® Category III Codes. Updated July 1, 2025 https://www.ama-assn.org/system/files/cpt-category3-codes-long-descriptors.pdf Accessed 03/18/2026.
2. Priority Health Category III Current Procedural Terminology (CPT) Codes effective date 08/2025 accessed on 03/18/2026.
3. Health Alliance Plan of Michigan Category III Codes effective date 06/23/2023 accessed on 03/18/2026.
4. 2026 Medica Medicare Prior Authorization and Notification Requirements effective date 03/01/2026 accessed on 03/18/2026.
5. Blue Cross Blue Shield Blue Care Network Michigan CPT Category III Codes-Noncovered Services effective date 03/01/2026 accessed on 03/18/2026
6. Local Coverage Article (LCA) Billing and Coding: Category III Codes – Wisconsin Physician Services Insurance Corporation; effective 08/29/2019 Article - Billing and Coding: Category III Codes (A56902) accessed on 03/18/2026
   https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56902&ver=50&
7. Local Coverage Determination (LCD) Category III Codes – Wisconsin Physician Services Insurance Corporation; effective date 10/1/2015 LCD - Category III Codes (L35490)
   https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35490&ver=85&keywordtype=starts&keyword=Category+III&bc=0

Policy Implementation/Update Information:

May 19, 2026 – Newly created policy. Due to the absence of NCD, LCD for Palmetto. (JM)

Approval Dates:

Physician Advisory Group Committee: August 18, 2026