Payer policies › CPT 0665T0665T CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 0665T 20 of 21 payer prior-auth lists that name 0665T require prior authorization or set conditions: Cigna, HealthSpring, 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).
Payer Plan State Prior auth Conditions Since Source Cigna ACA/IFP All prior auth required Jul 1, 2021 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required Jul 1, 2021 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required Jul 1, 2021 Master Precertification List (For Health Care Providers) HealthSpring Medicare Advantage All prior auth required Aug 1, 2026 2026 Q4 Prior Authorization List Humana Humana Healthy Horizons FL prior auth required Jan 1, 2027 1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List Humana Humana Healthy Horizons KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. Humana Humana Healthy Horizons LA prior auth required Jan 1, 2027 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate Humana Humana Healthy Horizons SC prior auth required Jan 1, 2027 Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical 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
Payer coverage policies that name 0665T 0665T appears in 11 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Capital Blue Cross, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Infertility (0327) not covered Jul 16, 2026 payer document Anthem Uterine Transplantation (TRANS.00037) unproven / investigational Feb 19, 2026 payer document Blue Cross & Blue Shield of Mississippi Uterus Transplantation For Absolute Uterine Factor Infertility unproven / investigational payer document Blue Cross & Blue Shield of Rhode Island Uterus Transplantation for Absolute Uterine Factor Infertility not covered Sep 16, 2026 payer document Blue Cross NC Infertility Diagnosis and Treatment – B0006 listed, no stance (range 0664T-0670T) Mar 1, 2026 payer document Capital Blue Cross Experimental and Investigational Procedures (MP 4.002)Procedure codes: Genitourinary listed, no stance Sep 1, 2026 payer document Cigna Infertility Services (0089) unproven / investigational Jun 15, 2025 payer document Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) Category III Current Procedural Terminology (CPT®) CodesCPT Codes 0054T, 0055T, 0071T, 0072T, 0075T, 0076T, 0095T, 0098T, 0100T, 0101T, listed, no stance Jan 1, 2027 payer document Premera Blue Cross Uterus Transplantation for Absolute Uterine Factor Infertility (4.02.06) listed, no stance Oct 27, 2025 payer document Regence Uterus Transplant (Transplant 19) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Omnibus Codes (MMP107.09)preservation); open, from cadaver donor | necessary; refer to the listed, no stance Jun 1, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, Oxford Health Plans Aug 1, 2026: PA added, HealthSpring Jan 1, 2026: PA removed, Molina Healthcare of Michigan Mar 1, 2025: PA removed, Rocky Mountain Health Plans Mar 1, 2025: PA removed, Rocky Mountain Health Plans 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 Jan 1, 2024: PA removed, Molina Healthcare of Michigan Jan 1, 2023: PA added, Molina Healthcare of Ohio 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.