17004 CPT® code: payer coverage and prior authorization19 of 20 payer prior-auth lists that name 17004 require prior authorization or set conditions: Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Neighborhood Health Partnership, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 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 New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| 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 South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| 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 | |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth under conditions | site of care: outpatient hospital | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 |
17004 appears in 16 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Actinic Keratoses Treatments (0567) | covered if criteria are met | Aug 21, 2026 | payer document |
| Aetna | Benign Skin Lesion Removal (0633) | covered if criteria are met (range 17000-17004) | Sep 9, 2026 | payer document |
| Aetna | Carbon Dioxide Laser (0427) | covered if criteria are met (range 17000-17004) | Jul 8, 2026 | payer document |
| Aetna | Cryoablation (0100) | listed, no stance (range 17000-17286) | Aug 4, 2026 | payer document |
| Aetna | Dermabrasion, Chemical Peels, and Acne Surgery (0251) | listed, no stance (range 17000-17250) | Apr 15, 2026 | payer document |
| Aetna | Laser Treatment for Psoriasis and Other Selected Skin Conditions (0577) | not covered (range 17000-17004) | Jul 15, 2026 | payer document |
| Aetna | Pulsed Dye Laser Treatment (0559) | covered if criteria are met | Sep 18, 2026 | payer document |
| Aetna | Rosacea (0547) | not covered | Aug 21, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 10040-19499) | Jul 29, 2026 | payer document |
| Anthem | Destruction of Pre-Malignant Skin Lesions (CG-SURG-37) | covered if criteria are met | Aug 13, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Nonpharmacologic Treatment Of Rosacea | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Removal Of Benign Skin Lesions And Scars (L.7.01.412) | covered if criteria are met | payer document | |
| Blue Cross Blue Shield of Massachusetts | Benign Skin Lesions (707) | listed, no stance | payer document | |
| Blue Cross Blue Shield of Massachusetts | Nonpharmacologic Treatment of Rosacea (462) | unproven / investigational | payer document | |
| Capital Blue Cross | Cosmetic and Reconstructive Surgery (MP 1.004) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Nonpharmacologic Treatment of Rosacea (THE801.030) CPT Codes 15260, 15261, 15780, 15781, 15782, 15783, 15788, 15789, 15792, | listed, no stance | May 1, 2026 | payer document |
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.