`0657T` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0657T

58 of 59 payer prior-auth lists that name 0657T require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required		Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required		Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jun 17, 2022	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jun 17, 2022	Master Precertification List (For Health Care Providers)
Cigna	Musculoskeletal	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Cigna	Musculoskeletal	All	prior auth required		Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Spine Surgery
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	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 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	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
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 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 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 Texas	Exchange	TX	prior auth required	PA Modernization - PA requirements will be removed where covered	Jan 1, 2024	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
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
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans 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
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required	site of care: site of service reviewed	Sep 1, 2026	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required	site of care: site of service reviewed	Sep 1, 2026	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 required	site of care: site of service reviewed	Sep 1, 2026	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
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required	site of care: site of service reviewed	Sep 1, 2026	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026

Payer coverage policies that name 0657T

0657T appears in 17 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Idiopathic Scoliosis (0398)	covered if criteria are met	Sep 28, 2026	payer document
Aetna	Spinal Surgery: Laminectomy and Fusion (0743)	listed, no stance	Jul 30, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Interventions For Progressive Scoliosis	unproven / investigational		payer document
Blue Cross & Blue Shield of Rhode Island	Interventions for Progressive Scoliosis MEDICAL COVERAGE POLICY \| 3	not covered	Jun 3, 2026	payer document
Cigna	Intraoperative Monitoring (0509)	not covered	Sep 15, 2025	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	Vertebral Body Tethering and Stapling (Surgery 232)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (CS170.K)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (2026T0605M)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Kansas Only) (CS170KS.02)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Kentucky Only) (CS170KY.09)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Nebraska Only) (CS170NE.K)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for New Mexico Only) (CS170NM.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for North Carolina Only) (CSNCT0605.04)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Ohio Only) (CS170OH.D)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Pennsylvania Only) (CS170PA.I)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Vertebral Body Tethering for Scoliosis (for Tennessee Only) (CS170TN.I)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: PA added, UnitedHealthcare
Oct 1, 2026: PA added, UnitedHealthcare
Oct 1, 2026: PA added, UnitedHealthcare Community Plan
Oct 1, 2026: PA added, UnitedHealthcare Community Plan
Oct 1, 2026: PA added, Surest
Oct 1, 2026: PA added, UnitedHealthcare
Sep 1, 2026: PA added, UnitedHealthcare Community Plan
Sep 1, 2026: PA added, Rocky Mountain Health Plans
Sep 1, 2026: PA added, UnitedHealthcare Community Plan
Sep 1, 2026: PA added, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in IN.

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.

0657T CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0657T

Payer coverage policies that name 0657T

Recent prior-auth changes

Medicaid fee-for-service

`0657T` CPT® code: payer coverage and prior authorization