Payer policies › CPT 3484334843 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 34843 27 of 28 payer prior-auth lists that name 34843 require prior authorization or set conditions: CarePlus Health Plans, Humana, 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 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 Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services Humana Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services Humana Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services 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 required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management 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 Medicaid MI prior auth required adults via Evolent Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 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 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
Payer coverage policies that name 34843 34843 appears in 9 coverage policies from Aetna, Blue Cross Blue Shield of Massachusetts, Premera Blue Cross.
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 Endovascular Repair of Aortic Diseases (0651) covered if criteria are met (range 34841-34844) Sep 25, 2026 payer document Aetna Negative Pressure Wound Therapy (0334) listed, no stance (range 33016-37799) Jun 8, 2026 payer document Aetna Nitric Oxide, Inhalational (INO) (0518) not covered (range 33016-37790) Jul 2, 2026 payer document Aetna Stereolithographic Models and Implants (0613) listed, no stance (range 33010-37790) Sep 3, 2026 payer document Blue Cross Blue Shield of Massachusetts Endovascular Grafts for Abdominal Aortic Aneurysms (098) listed, no stance payer document Premera Blue Cross Endovascular Stent Grafts for Abdominal Aortic Aneurysms (7.01.601)Page | 4 of 20 | ∞ listed, no stance Aug 18, 2026 payer document
Recent prior-auth changes Jan 1, 2026: PA added, Molina Healthcare of Michigan Jul 1, 2024: PA added, Molina Healthcare of Mississippi Jan 1, 2024: PA added, Molina Healthcare of Michigan Medicaid fee-for-service Prior authorization required or conditional in IN.
AZ: $1640.39 (physician, AHCCCS PT 08, facility), effective Oct 1, 2020 IL: $1287.90 (practitioner), effective Jan 1, 2014 IN: $1173.02 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2024 KS: $673.05 (default, Exempt Physician), effective Aug 1, 2024 KY: $0.00 (physician, facility), effective Jan 1, 2026 LA: $2114.68 (professional), effective Aug 1, 2016 ND: $0.00 (physician), effective Aug 1, 2026 NE: $163.02 (physician, non-facility), effective Jul 1, 2026 NY: $1168.40 (physician_surgery, facility), effective Jul 1, 2026 OH: $1150.28 (physician), effective Jul 1, 2019 OK: $2875.34 (physician, non-facility), effective Jul 1, 2026 TX: $2580.57 (physician, Physician, facility), effective Sep 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $1602.19 (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.