`0573T` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0573T

35 of 36 payer prior-auth lists that name 0573T require prior authorization or set conditions: CarePlus Health Plans, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Oxford Health Plans, and others.

Payer	Plan	State	Prior auth	Since	Source
HealthSpring	Medicare Advantage	All	prior auth required	Aug 1, 2026	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Cardiology Services	All	prior auth required		Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
Humana	Cardiology Services	All	prior auth required		Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
Humana	Cardiology Services	All	prior auth required		Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
Humana	Humana D-SNP (FL)	FL	prior auth required	Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required	Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required	Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required	Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required	Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required	Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required	Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana MA and D-SNP	All	prior auth required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required	Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required		Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required	Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required	Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicare Advantage	CA	prior auth required	Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Iowa	Medicaid	IA	prior auth required	Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required	Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Nevada	Medicaid	NV	prior auth required	Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required	Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required	Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required	Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required	Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	Exchange	TX	prior auth required	Apr 1, 2020	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required	Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required	Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required	Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Oxford Health Plans	Oxford Health Plans	All	prior auth required	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare West commercial plans	All	prior auth required	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026

Payer coverage policies that name 0573T

0573T appears in 7 coverage policies from Aetna, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Cardioverter-Defibrillators (0585)	covered if criteria are met	Apr 22, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Implantable Cardioverter Defibrillator (070)	unproven / investigational		payer document
Blue Cross NC	Implantable Cardioverter Defibrillator	listed, no stance	Jun 1, 2026	payer document
Blue Shield of California	\| Implantable Cardioverter Defibrillators (7.01.44)	listed, no stance		payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Category III Current Procedural Terminology (CPT®) Codes CPT Codes 0054T, 0055T, 0071T, 0072T, 0075T, 0076T, 0095T, 0098T, 0100T, 0101T,	listed, no stance	Jan 1, 2027	payer document
Regence	Extravascular (Substernal) Implantable Cardioverter-Defibrillator (Surgery 17)	listed, no stance	Jun 1, 2025	payer document
UnitedHealthcare	Omnibus Codes (MMP107.09) electrode \| NCD for Implantable	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Aug 1, 2026: PA added, HealthSpring
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Jan 1, 2025: PA removed, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in IN.

IN: $0.00 (professional, facility), effective Jan 1, 2020
KS: $295.86 (default, Exempt Physician), effective Jan 1, 2020
ND: $0.00 (physician), effective Aug 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

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.

0573T CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0573T

Payer coverage policies that name 0573T

Recent prior-auth changes

Medicaid fee-for-service

`0573T` CPT® code: payer coverage and prior authorization