Category III Codes – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare generally treats AMA Category III CPT codes as experimental, investigational, or not medically necessary and excludes them from coverage unless a specific UnitedHealthcare policy, the member’s benefit plan, or federal/state law requires coverage (services in qualifying clinical trials may be an exception). Coverage requires referencing the member-specific benefit document, objective evidence of efficacy and documented medical necessity, and compliance with applicable federal/state mandates or Medicare guidance.

"The procedures, services, or items represented by these codes are generally considered experimental, investigational, or unproven and not medically necessary due to insufficient evidence of efficac..."

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