Coverage Policy

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Medical Coverage Policy: 0558

Guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies.

In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation.

Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

Related Coverage Resources

In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

Coverage Policy Details

This Coverage Policy addresses CPT® Category III Codes, which are a set of temporary (T) codes for emerging technologies, services, and procedures. They have an alpha character as the 5th character in the string (i.e., four digits followed by the letter T) and are also referred to as T Codes. There may be some T codes that are considered medically appropriate based on peer-reviewed scientific literature.

Certain T codes which may be recommended for coverage if coverage criteria are met are addressed in the relevant coverage policies listed under the Related Coverage Resources heading above.

Therefore, unless there is a Cigna Coverage Policy that specifically extends coverage to a particular Category III code, the code would generally be considered experimental, investigational, or unproven.

General Background

CPT Category III codes are a set of temporary (T) codes assigned to emerging technologies, services, and procedures. These codes are intended to be used for data collection to substantiate more widespread usage or to provide documentation for the Food and Drug Administration (FDA) approval process. Category III codes can be identified by the T alpha character that follows the four initial numerical digits (i.e., four digits followed by the letter T).

These codes are also referred to as T Codes (American Medical Association [AMA], 2019).

Medical Coverage Policy: 0558

The use of a Category III code allows physicians and other qualified health care professionals to identify emerging technologies, services and procedures for clinical efficacy, utilization and outcomes. Category III codes are generally archived after five years and may or may not eventually receive a Category I CPT code. If a specific cross-referenced Category I code has not been established at the time of archiving, the service or procedure will be reported with a Category I unlisted code (AMA, 2019). It is noted by the AMA that a service or procedure represented by a T code does not constitute a finding of support, or lack thereof with regard to clinical efficacy, safety, applicability or clinical practice. Typically, there is a lack of published, peer-review evidence supporting the clinical efficacy, safety, and applicability of these services to clinical practice nor are these services considered an established standard of care.

Related Coverage Policies that consider specific Category III codes medically necessary for some indications include the following:

• Coverage Policy Ambulatory External and Implantable Electrocardiographic Monitoring
• Category III CPT Code(s) 0497T, 0498T, 0650T
• Angioplasty (Extracranial, Intracranial) and Intracranial Aneurysm Repair
• Axicabtagene ciloleucel
• Behavioral Health Coaching and Peer Support Services
• Brexucabtagene autoleucel
• Corneal Remodeling for Refractive Errors
• Diabetes Equipment and Supplies
• Glaucoma Surgical Procedures
• eviCore Adult Cardiac Imaging guideline
• eviCore Pediatric Cardiac Imaging guideline
• eviCore Adult Head Imaging guideline
• Fecal Bacteriotherapy
• Idecabtagene vicleucel
• Intervertebral Disc (IVD) Prostheses
• Intensive Behavioral Interventions
• Lisocabtagene maraleucel
• Omnibus Codes
• Pancreatic Islet Cell Transplantation
• Percutaneous Revascularization of the Lower Extremities in Adults 0505T
• Preventive Care Services
• Scar Revision
• Tisagenlecleucel
• Transcatheter Heart Valve Procedures 0403T, 0488T, 0500T
• 0479T, 0480T
• 0537T, 0538T, 0539T, 0540T
• 0483T