`0765T` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0765T

3 of 3 payer prior-auth lists that name 0765T require prior authorization or set conditions: HealthSpring, Oxford Health Plans, UnitedHealthcare.

Payer	Plan	State	Prior auth	Since	Source
HealthSpring	Medicare Advantage	All	prior auth required	Aug 1, 2026	2026 Q4 Prior Authorization List
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 0765T

0765T appears in 6 coverage policies from Aetna, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Signal-Averaged Electrocardiography (SAECG) and Artificial Intelligence Algorithmic Electrocardiogram (0664)	not covered	Oct 7, 2026	payer document
Capital Blue Cross	Experimental and Investigational Procedures (MP 4.002) Procedure codes: Cardiac	listed, no stance	Sep 1, 2026	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
Premera Blue Cross	Non-covered Experimental/Investigational Services Page \| 9 of 38 \| ∞	listed, no stance	Oct 1, 2026	payer document
Regence	New and Emerging Medical Technologies and Procedures (Medicine 149) perianal perifistular soft tissue, \| Pharmaceuticals	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Category III Codes (2026T0644Q)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Aug 1, 2026: PA added, HealthSpring

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.

0765T CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 0765T

Payer coverage policies that name 0765T

Recent prior-auth changes

Medicaid fee-for-service

`0765T` CPT® code: payer coverage and prior authorization