`31295` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 31295

95 of 96 payer prior-auth lists that name 31295 require prior authorization or set conditions: Aetna, Blue Shield of California, CarePlus Health Plans, Cigna, Humana, 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 Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California	Blue Shield Medicare	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield Medicare
Blue Shield of California	Blue Shield commercial	CA	prior auth under conditions	CalPERS ASO only	Sep 1, 2026	Prior Authorization List for Blue Shield
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Aetna	Commercial	All	prior auth required	site of care: procedure and site of service review	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Aug 26, 2016	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Aug 26, 2016	Master Precertification List (For Health Care Providers)
Cigna	Other Services	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Cigna	Other Services	All	prior auth required		Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Other Services
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 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 under conditions	Excludes diagnostic nasal/sinus endoscopies		Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
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 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 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 California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
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 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 Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
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 Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
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 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 Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
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 Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
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
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth under conditions	site of care: outpatient hospital, ASC; 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
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 Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME 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
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth required		Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans 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
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth under conditions	site of care: outpatient hospital; not in AK, IL, MA, PR, RI, TX, UT, VI, WI	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth required		Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth required		Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth required		Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026

Payer coverage policies that name 31295

31295 appears in 25 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Capital Blue Cross, Centene, Cigna, Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Myringotomy and Tympanostomy Tube (0418)	listed, no stance (range 31231-31297)	Jun 30, 2026	payer document
Aetna	Sinus Surgeries (0937)	covered if criteria are met	Apr 10, 2026	payer document
Aetna	Tezepelumab-ekko (Tezspire) (1003)	listed, no stance (range 30000-31299)	Aug 6, 2026	payer document
Anthem	Balloon Sinus Ostial Dilation (CG-SURG-73)	covered if criteria are met	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Balloon Ostial Dilation For Treatment Of Chronic And Recurrent Acute Rhinosinusitis (A.7.01.105)	listed, no stance		payer document
Blue Cross Blue Shield of Massachusetts	Balloon Sinuplasty for Treatment of Chronic Sinusitis (582)	listed, no stance		payer document
Blue Cross NC	Balloon Ostial Dilation (Balloon Sinuplasty)	listed, no stance	Feb 1, 2026	payer document
Blue Cross NC	Professional Pathology Billing Requirements AHS – R2169	listed, no stance (range 3011F-3210F)	Mar 1, 2024	payer document
Capital Blue Cross	Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis (MP 1.119) Procedure codes	covered if criteria are met	Jun 1, 2026	payer document
Centene	Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (CP.MP.119)	covered if criteria are met	Sep 1, 2020	payer document
Cigna	Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation (0480)	covered if criteria are met	Apr 15, 2026	payer document
Premera Blue Cross	Sinus Surgery in Adults (7.01.559) Page \| 10 of 37 \| ∞	listed, no stance	Oct 14, 2026	payer document
UnitedHealthcare	Ear, Nose, and Throat Procedures (MMP060.17) Balloon Sinus Ostial Dilation (Also Known as Balloon Dilation Sinuplasty)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (CS138.T)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (2026T0571U)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Idaho Only) (CS138ID.D)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Kansas Only) (CS138KS.03)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Kentucky Only) (CS138KY.13)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Nebraska Only) (CS138NE.U)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for New Jersey Only) (CS138NJ.O)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for New Mexico Only) (CS138NM.D)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for North Carolina Only) (CSNCT0571.06)	listed, no stance	Aug 1, 2025	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Ohio Only) (CS138OH.D)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Pennsylvania Only) (CS138PA.Q)	listed, no stance	Aug 1, 2025	payer document
UnitedHealthcare	Sinus Surgeries and Interventions (for Tennessee Only) (CS138TN.Q)	listed, no stance	Aug 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare
Sep 1, 2026: conditions changed, UnitedHealthcare
Aug 1, 2026: PA removed, HealthSpring
Jul 1, 2026: conditions changed, Neighborhood Health Partnership
Jul 1, 2026: conditions changed, UnitedHealthcare
Jul 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Mar 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Jan 1, 2026: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

AZ: $2073.57 (asc), effective Oct 1, 2026
CO: $1329.29 (chp_plus, non-facility), effective Jul 1, 2026
IL: $108.09 (practitioner), effective Apr 1, 2024
IN: $121.26 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $738.48 (asc, facility), effective Jan 1, 2011
KY: $3031.41 (asc), effective Jan 1, 2026
LA: $1238.88 (professional), effective Jul 1, 2025
MA: $1548.22 (asc), effective May 1, 2026
MS: $2459.74 (comprehensive, facility), effective Oct 1, 2025
ND: $1787.02 (physician, facility), effective Aug 1, 2026
NY: $137.72 (physician_surgery, facility), effective Jul 1, 2026
OH: $84.42 (physician, facility), effective Jan 1, 2024
TX: $1349.92 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $116.90 (medical, facility), effective Jul 1, 2026
VT: $5479.84 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $78.73 (physician, facility), effective Jul 1, 2026
WY: $3121.07 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.

31295 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 31295

Payer coverage policies that name 31295

Recent prior-auth changes

Medicaid fee-for-service

`31295` CPT® code: payer coverage and prior authorization