00170 CPT® code: payer coverage and prior authorization7 of 7 payer prior-auth lists that name 00170 require prior authorization or set conditions: Blue Shield of California, Blue Shield of California Promise Health Plan, Molina Healthcare of Texas, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth under conditions | place of service 19 | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth under conditions | Age under 21; Prior authorization is required for members younger than 21 when billed with Modifier U3. | Jul 1, 2017 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth under conditions | Age under 21; Prior authorization is required, for members younger than age 21, when billed with modifier U3. | Jul 1, 2017 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki |
00170 appears in 8 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Centene, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082) | covered if criteria are met (range 00170-00192) | Mar 18, 2026 | payer document |
| Aetna | General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124) | covered if criteria are met (range 00170-00176) | Mar 19, 2026 | payer document |
| Aetna | Manipulation Under General Anesthesia (0204) | listed, no stance | Mar 25, 2026 | payer document |
| Anthem | Anesthesia Services and Moderate (“Conscious”) Sedation (CG-MED-21) | covered if criteria are met (range 00100-00222) | Nov 6, 2025 | payer document |
| Anthem | Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting (CG-MED-41) | covered if criteria are met | May 14, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Pediatric Dental Anesthesia (L.7.02.402) | listed, no stance | payer document | |
| Centene | IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) | covered if criteria are met | Jun 1, 2026 | payer document |
| Premera Blue Cross | General Anesthesia and Facility Services Related to Dental Treatment | listed, no stance | Jan 12, 2026 | payer document |
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.