Payer policies › CPT 0770T0770T CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 0770T 10 of 11 payer prior-auth lists that name 0770T require prior authorization or set conditions: Molina Complete Care (Virginia), Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Mississippi, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah.
Payer Plan State Prior auth Conditions Since Source Molina Complete Care (Virginia) Medicaid VA prior auth required Apr 1, 2025 Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 Molina Healthcare of Idaho Medicaid ID prior auth required Jan 1, 2025 Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 Molina Healthcare of Iowa Medicaid IA prior auth required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 Molina Healthcare of Mississippi Medicaid MS prior auth required Jan 1, 2025 Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 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 STAR TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 Molina Healthcare of Texas STAR+PLUS TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 Molina Healthcare of Utah Medicaid UT prior auth required Jan 1, 2025 Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Payer coverage policies that name 0770T 0770T appears in 9 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence.
Payer Policy Role in policy Reviewed Document Aetna Cognitive Rehabilitation (0214) not covered Apr 21, 2026 payer document Aetna Multiple Sclerosis (0264) not covered Sep 10, 2026 payer document Anthem Virtual Reality-Assisted Therapy Systems (DME.00048) unproven / investigational May 14, 2026 payer document Blue Cross & Blue Shield of Mississippi Immersive Virtual Reality Therapy For Chronic Lower Back Pain unproven / investigational payer document Capital Blue Cross Experimental and Investigational Procedures (MP 4.002)Procedure codes: Miscellaneous listed, no stance Sep 1, 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 Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) Immersive Virtual Reality Therapy for Chronic Lower Back Pain (PSY301.026) listed, no stance Nov 1, 2026 payer document Premera Blue Cross Non-covered Experimental/Investigational ServicesPage | 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
Recent prior-auth changes Aug 1, 2026: PA removed, HealthSpring Aug 1, 2026: PA added, HealthSpring Jul 1, 2026: PA removed, Molina Healthcare of Texas Jan 1, 2026: PA removed, Passport by Molina Healthcare (Kentucky) Jan 1, 2026: PA removed, Molina Healthcare of Illinois Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jan 1, 2023: PA added, Molina Healthcare of Texas 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.