Payer policies › CPT 0817T0817T CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 0817T 13 of 13 payer prior-auth lists that name 0817T require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, HealthSpring, Humana.
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) 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 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 Healthy Horizons VA prior auth required Jan 1, 2027 Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) 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 Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Payer coverage policies that name 0817T 0817T appears in 5 coverage policies from Aetna, Anthem, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence.
Payer Policy Role in policy Reviewed Document Aetna Urinary Incontinence (0223) not covered Jul 16, 2026 payer document Anthem Tibial Nerve Stimulation (CG-SURG-126) covered if criteria are met Feb 19, 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 Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions (7.01.574) listed, no stance Jul 1, 2026 payer document Regence Subcutaneous Tibial Nerve Stimulation (Surgery 154) listed, no stance Dec 1, 2025 payer document
Recent prior-auth changes Aug 1, 2026: PA added, HealthSpring Jan 1, 2024: PA added, humana:pa:commercial Medicaid fee-for-service Prior authorization required or conditional in IN.
KY: $16329.12 (asc), effective Jan 1, 2026 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.