33367 CPT® code: payer coverage and prior authorization14 of 15 payer prior-auth lists that name 33367 require prior authorization or set conditions: Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, 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 Utah, Passport by Molina Healthcare (Kentucky).
| 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 California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| 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 Illinois | Medicaid | IL | prior auth required | Apr 1, 2023 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | adults via Evolent | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | adults via Evolent | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | adults via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | adults via NCH | 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 Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth under conditions | no PA under 18 | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Exchange | OH | prior auth under conditions | no PA under 18 | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| 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 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | adults via Evolent | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
33367 appears in 35 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Anesthetic and Antiemetic Infusion Pumps (0607) | listed, no stance (range 33016-37799) | Sep 9, 2026 | payer document |
| Aetna | Balloon Valvuloplasty (0477) | listed, no stance (range 33361-33369) | Jul 17, 2026 | payer document |
| Aetna | Bupivacaine Liposome (Exparel) (0941) | listed, no stance (range 33010-37799) | Jul 30, 2026 | payer document |
| Aetna | Cardiac Computed Tomography (CT), Coronary CT Angiography, Calcium Scoring and CT Fractional Flow Reserve (0228) | listed, no stance (range 33361-33369) | Jul 21, 2026 | payer document |
| Aetna | Cardiac Rehabilitation: Outpatient (0021) | listed, no stance (range 33361-33369) | Mar 10, 2026 | payer document |
| Aetna | Cardiovascular Ultrafiltration (0741) | listed, no stance (range 33010-37790) | Oct 30, 2025 | payer document |
| Aetna | Cryoanalgesia and Therapeutic Cold (0297) | listed, no stance (range 33016-33999) | Apr 14, 2026 | payer document |
| Aetna | Functional Electrical Stimulation and Neuromuscular Electrical Stimulation (0677) | listed, no stance (range 33016-33999) | Sep 10, 2026 | payer document |
| Aetna | Inpatient Admission Prior to Surgery (Preop Days) (0255) | listed, no stance (range 33016-33980) | May 13, 2026 | payer document |
| Aetna | Intraoperative Neurophysiological Monitoring (0697) | covered if criteria are met (range 33361-33369) | Jun 19, 2026 | payer document |
| Aetna | Intravenous Iron Therapy (0575) | listed, no stance (range 33016-33999) | Jul 1, 2026 | payer document |
| Aetna | Negative Pressure Wound Therapy (0334) | listed, no stance (range 33016-37799) | Jun 8, 2026 | payer document |
| Aetna | Nerve Blocks (0863) | listed, no stance (range 33016-33999) | Jul 23, 2026 | payer document |
| Aetna | Nitric Oxide, Inhalational (INO) (0518) | not covered (range 33016-37790) | Jul 2, 2026 | payer document |
| Aetna | Procalcitonin (PCT) (0771) | listed, no stance (range 33016-33997) | Nov 13, 2025 | payer document |
| Aetna | Stereolithographic Models and Implants (0613) | listed, no stance (range 33010-37790) | Sep 3, 2026 | payer document |
| Aetna | Transcatheter Aortic Valve Implantation (0826) | listed, no stance | Dec 3, 2025 | payer document |
| Anthem | Transcatheter Aortic Heart Valve Procedures (CG-SURG-131) | covered if criteria are met | Aug 13, 2026 | payer document |
| Anthem | Transcatheter Mitral, Pulmonary, and Tricuspid Heart Valve Procedures (SURG.00121) | covered if criteria are met | Feb 19, 2026 | payer document |
| Anthem | Transcatheter Mitral, Pulmonary, and Tricuspid Heart Valve Procedures (SURG.00121) | unproven / investigational | Feb 19, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Transcatheter Aortic Valve Implantation For Aortic Stenosis (A.7.01.132) | covered if criteria are met | payer document | |
| Blue Cross Blue Shield of Massachusetts | Transcatheter Aort (392) | listed, no stance | payer document | |
| Premera Blue Cross | Transcatheter Aortic-Valve Implantation for Aortic Stenosis (7.01.132) Page | 3 of 33 | ∞ | listed, no stance | Oct 1, 2026 | payer document |
| Regence | Transcatheter Aortic Valve Implantation for Aortic Stenosis (Surgery 201) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (2026T0557FF) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (CS123.X) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Idaho Only) (CS123ID.C) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Kansas Only) (CS123KS.03) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Kentucky Only) (CS123KY.14) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Nebraska Only) (CS123NE.V) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for New Jersey Only) (CS123NJ.S) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for New Mexico Only) (CS123NM.D) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for North Carolina Only) (CSNCT0557.06) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Ohio Only) (CS123OH.F) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Pennsylvania Only) (CS123PA.X) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Transcatheter Procedures for Heart Valve Conditions (for Tennessee Only) (CS123TN.W) | listed, no stance | Aug 1, 2026 | payer document |
Prior authorization required or conditional in WA.
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.