Payer policies › CPT 3390433904 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 33904 12 of 12 payer prior-auth lists that name 33904 require prior authorization or set conditions: Molina Complete Care (Virginia), Molina Healthcare of Idaho, Molina Healthcare of Illinois, 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 Illinois Medicaid IL prior auth required Jan 1, 2022 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 Mississippi Medicaid MS prior auth required 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 Texas Exchange TX prior auth required Jan 1, 2023 Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 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
Payer coverage policies that name 33904 33904 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
Recent prior-auth changes Jul 1, 2026: PA removed, Molina Healthcare of Texas Jan 1, 2026: PA removed, Molina Healthcare of Michigan Oct 1, 2025: PA removed, Passport by Molina Healthcare (Kentucky) Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jul 1, 2024: PA added, Molina Healthcare of Michigan Apr 1, 2023: conditions changed, Molina Healthcare of Ohio Apr 1, 2023: conditions changed, Molina Healthcare of Ohio Jan 1, 2023: PA added, Molina Healthcare of Texas Jan 1, 2023: PA added, Molina Healthcare of Ohio Medicaid fee-for-service AZ: $295.32 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $232.41 (health_first_colorado), effective Jul 1, 2026 FL: $62.58 (physician, non-facility), effective Jan 1, 2026 IL: $200.54 (practitioner), effective Apr 1, 2024 IN: $217.14 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $138.10 (default, Exempt Physician), effective Aug 1, 2024 KY: $243.50 (physician, facility), effective Jan 1, 2026 LA: $259.75 (professional), effective Jan 1, 2023 MA: $210.09 (physician_surgery), effective May 1, 2024 MS: $217.04 (comprehensive), effective Jul 1, 2026 ND: $260.22 (physician), effective Aug 1, 2026 NE: $533.52 (physician, non-facility), effective Jul 1, 2026 OH: $224.75 (physician), effective Jan 1, 2023 OK: $228.36 (physician, non-facility), effective Jul 1, 2026 TX: $216.12 (physician, Physician, facility), effective Sep 1, 2026 VA: $222.80 (medical, facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $146.19 (physician, facility), effective Jul 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.