Payer policies › CPT 0686T0686T CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 0686T 18 of 18 payer prior-auth lists that name 0686T require prior authorization or set conditions: CarePlus Health Plans, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of Iowa, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Texas, Oxford Health Plans, Rocky Mountain Health Plans, UnitedHealthcare.
Payer Plan State Prior auth Conditions 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 New PA requirement 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 New PA requirement 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 (VA) VA prior auth required New PA requirement Jan 1, 2027 Virginia Prior Authorization and Notification List Humana Humana MA and D-SNP All prior auth required New PA requirement Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List 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 Iowa Medicaid IA prior auth required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 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 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 Medicare Advantage D-SNP CO prior auth required Feb 1, 2025 Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 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 0686T 0686T appears in 8 coverage policies from Aetna, Anthem, Blue Shield of California, Capital Blue Cross, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Ablation of Hepatic Lesions (0274) not covered Jun 8, 2026 payer document Anthem Histotripsy (SURG.00165) covered if criteria are met Aug 13, 2026 payer document Blue Shield of California BSC9.01 | Investigational Services listed, no stance payer document Capital Blue Cross Experimental and Investigational Procedures (MP 4.002)Procedure codes: Endocrinology listed, no stance Sep 1, 2026 payer document Cigna Category III Current Procedural Terminology (CPT®) codes (0558) unproven / investigational Sep 15, 2026 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 Non-covered Experimental/Investigational ServicesPage | 6 of 38 | ∞ listed, no stance Oct 1, 2026 payer document UnitedHealthcare Omnibus Codes (for Ohio Only) (CS087OH.G) listed, no stance Sep 1, 2026 payer document
Recent prior-auth changes Jan 1, 2027: PA added, Humana Jan 1, 2027: PA added, CarePlus Health Plans Jan 1, 2027: PA added, CarePlus Health Plans Jan 1, 2027: PA added, Humana Jan 1, 2027: PA added, Humana Jan 1, 2027: PA added, Humana Jan 1, 2027: PA added, Humana Jan 1, 2027: PA added, Humana Aug 1, 2026: PA added, HealthSpring Mar 1, 2025: PA removed, Rocky Mountain Health Plans Medicaid fee-for-service Prior authorization required or conditional in IN.
AZ: $5144.40 (asc), effective Oct 1, 2026 KY: $9177.92 (asc), effective Jan 1, 2026 ND: $5410.39 (physician, facility), 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.