65765 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 65765

21 of 21 payer prior-auth lists that name 65765 require prior authorization or set conditions: Rocky Mountain Health Plans, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Rocky Mountain Health PlansRocky Mountain Health Plans CHP+COprior auth requiredOct 1, 2026Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Health Plans Prime / RAECOprior auth requiredOct 1, 2026Rocky Mountain Health Plans PRIME Effective October 1, 2026
UnitedHealthcare Community PlanDistrict of Columbia LTSSDCprior auth requiredOct 1, 2026Prior Authorization Requirements for District of Columbia LTSS Effective October 1, 2026
UnitedHealthcare Community PlanKanCareKSprior auth requiredOct 1, 2026Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community PlanLouisiana Medicaid (Healthy Louisiana)LAprior auth requiredJan 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community PlanMinnesota Metro MedicaidMNprior auth requiredOct 1, 2024Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community PlanMississippi CHIPMSprior auth requiredApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMissouri MedicaidMOprior auth requiredJul 1, 2026Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community PlanNew Jersey FamilyCareNJprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community PlanPennsylvania CHIPPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanTennCareTNprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of Hawaii (QUEST Integration)HIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJan 1, 2015Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community PlanVirginia Cardinal Care LTSSVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community PlanVirginia Cardinal Care MedicaidVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth requiredOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community PlanWisconsin BadgerCare Plus and Medicaid SSIWIprior auth requiredSep 1, 2026Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 65765

65765 appears in 6 coverage policies from Aetna, Anthem, Blue Cross Blue Shield of Massachusetts.

PayerPolicyRole in policyReviewedDocument
AetnaAnterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging (0749)listed, no stanceNov 26, 2025payer document
AetnaComputerized Corneal Topography (0130)listed, no stance (range 65710-65775)Mar 26, 2026payer document
AetnaCorneal Pachymetry (0681)listed, no stance (range 65710-65775)Oct 15, 2025payer document
AetnaCorneal Remodeling (0023)not coveredOct 9, 2026payer document
AnthemRefractive Surgery (CG-SURG-77)not coveredNov 6, 2025payer document
Blue Cross Blue Shield of MassachusettsVision Services (675)unproven / investigationalpayer document

Recent prior-auth changes

  • Mar 1, 2025: PA added, Rocky Mountain Health Plans
  • Mar 1, 2025: PA added, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in IN, KY.

  • CO: $935.31 (chp_plus, non-facility), effective Jul 1, 2026
  • IL: $1560.80 (practitioner), effective Jul 1, 2026
  • KS: $547.50 (default, Exempt Physician), effective Jul 1, 1987
  • KY: $45.00 (asc), effective Jan 1, 2026
  • LA: $963.52 (professional), effective Feb 1, 2013
  • ND: $0.00 (physician), effective Aug 1, 2026
  • NY: $867.73 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $666.62 (physician), effective Jan 1, 2017
  • VA: $841.01 (medical), effective Jul 1, 2009
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 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.