Payer policies › CPT 4961749617 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 49617 1 of 1 payer prior-auth lists that name 49617 require prior authorization or set conditions: Blue Shield of California Promise Health Plan.
Payer Plan State Prior auth Conditions Since Source Blue Shield of California Promise Health Plan Promise Health Plan Medi-Cal CA prior auth required Sep 1, 2026 Medi-Cal Prior Authorization List
Payer coverage policies that name 49617 49617 appears in 3 coverage policies from Aetna, Premera Blue Cross.
Payer Policy Role in policy Reviewed Document Aetna Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair (0211) covered if criteria are met Aug 18, 2026 payer document Aetna Cosmetic Surgery and Procedures (0031)Thermal therapy (e.g., radiofrequency (ThermiVa and Viveve procedures) and laser), Laviv (azficel-T) not covered Jun 25, 2026 payer document Premera Blue Cross Abdominal Wall Hernia Repair in Adults (7.01.600)Page | 3 of 14 | ∞ listed, no stance May 11, 2026 payer document
Recent prior-auth changes Feb 15, 2023: PA added, Blue Shield of California Promise Health Plan Medicaid fee-for-service Prior authorization required or conditional in WV.
AZ: $905.84 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $715.00 (health_first_colorado), effective Jul 1, 2026 FL: $209.78 (physician, non-facility), effective Jan 1, 2026 IL: $627.48 (practitioner), effective Apr 1, 2024 IN: $664.99 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $419.43 (default, Exempt Physician), effective Aug 1, 2024 KY: $743.36 (physician, facility), effective Jan 1, 2026 LA: $796.30 (professional), effective Jan 1, 2023 MA: $644.02 (physician_surgery), effective May 1, 2024 MS: $676.99 (comprehensive), effective Jul 1, 2026 ND: $819.32 (physician), effective Aug 1, 2026 NE: $1662.00 (asc), effective Jul 1, 2024 NY: $495.34 (physician_surgery, facility), effective Jul 1, 2026 OH: $688.72 (physician), effective Jan 1, 2023 OK: $713.63 (physician, non-facility), effective Jul 1, 2026 TX: $679.23 (physician, Physician, facility), effective Sep 1, 2026 VA: $700.23 (medical, facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $461.70 (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.