33902 CPT® code: payer coverage and prior authorization10 of 11 payer prior-auth lists that name 33902 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 | adults via Evolent | 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 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 | Medicare and MyCare Ohio (MMP) Medicare | 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 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 |
33902 appears in 13 coverage policies from Aetna.
| 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 | Bupivacaine Liposome (Exparel) (0941) | listed, no stance (range 33010-37799) | Jul 30, 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 | Endovascular Repair of Aortic Diseases (0651) | covered if criteria are met (range 33900-33904) | Sep 25, 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 | 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 |
Prior authorization required or conditional in VT.
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.