Payer policies › CPT 7601776017 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 76017 1 of 1 payer prior-auth lists that name 76017 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 76017 76017 appears in 1 coverage policy from Premera Blue Cross.
Payer Policy Role in policy Reviewed Document Premera Blue Cross Non-covered Services and ProceduresPage | 8 of 30 | ∞ listed, no stance Jun 1, 2026 payer document
Recent prior-auth changes Feb 1, 2025: PA added, Blue Shield of California Promise Health Plan Medicaid fee-for-service Prior authorization required or conditional in IN.
AZ: $166.84 (outpatient_hospital), effective Oct 1, 2025 CO: $191.06 (chp_plus, non-facility), effective Jul 1, 2026 IN: $172.43 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KY: $178.69 (physician, facility), effective Jan 1, 2026 LA: $59.04 (lab_radiology), effective Jan 1, 2025 ND: $37.92 (physician), effective Aug 1, 2026 OH: $161.83 (physician), effective Jan 1, 2025 TX: $190.58 (miscellaneous_other_professionals_portable_x_ray_radiologica, Miscellaneous Other Professionals - Portable X-Ray, Radiological Lab, Physiological Lab, facility), effective Apr 1, 2025 VA: $162.04 (medical, facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $105.52 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.