76377 CPT® code: payer coverage and prior authorization54 of 54 payer prior-auth lists that name 76377 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, 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 South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | FEP Blue Focus only | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | eviCore-delegated groups only; Gold-card eligible | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Gold-card eligible | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | eviCore-managed | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Carelon-managed | Jan 1, 2021 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| Humana | Humana Healthy Horizons | KY | prior auth required | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| 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 Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| 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 California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| 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 Idaho | Medicare Advantage | ID | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| 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 Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Contact eviCore for PA | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 |
| 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 Nevada | Medicaid | NV | prior auth required | 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 New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | 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 required | 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 South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| 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 | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Sep 1, 2019 | 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 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| Oxford Health Plans | Oxford Health Plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) and OneCare | MA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | North Carolina Medicaid | NC | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024 | |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care | |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h | |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth required | Nov 1, 2016 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki | |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p | |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
76377 appears in 29 coverage policies from Aetna, Anthem, Centene, Cigna, Premera Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Alopecia Areata (0423) | not covered | Jul 10, 2026 | payer document |
| Aetna | Breast Biopsy Procedures (0269) | not covered | May 14, 2026 | payer document |
| Aetna | Endometrial Ablation (0091) | not covered (range 76376-76377) | Mar 25, 2026 | payer document |
| Aetna | Lung Imaging: Selected Techniques (0581) | not covered | Sep 10, 2026 | payer document |
| Aetna | Shoulder Arthroplasty and Arthrodesis (0837) | not covered | Jun 25, 2026 | payer document |
| Aetna | Stereolithographic Models and Implants (0613) | listed, no stance | Sep 3, 2026 | payer document |
| Aetna | Transrectal Ultrasound (0001) | not covered | Mar 5, 2026 | payer document |
| Aetna | Ultrasound for Pregnancy (0199) | not covered | Mar 24, 2026 | payer document |
| Aetna | Vitiligo (0422) | not covered | Jul 16, 2026 | payer document |
| Anthem | Three-Dimensional (3-D) Rendering of Imaging Studies (CG-RAD-31) | covered if criteria are met | Aug 13, 2026 | payer document |
| Anthem | Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care (RAD.00038) | unproven / investigational | Feb 19, 2026 | payer document |
| Centene | Ultrasound in Pregnancy (CP.MP.38) | not covered | Oct 1, 2023 | payer document |
| Cigna | Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) (0142) | not covered | Aug 15, 2026 | payer document |
| Premera Blue Cross | Orthognathic Surgery (9.02.501) Page | 7 of 19 | ∞ | listed, no stance | May 12, 2026 | payer document |
| Premera Blue Cross | Preventive Care Breast biopsies and biopsy accessories | covered if criteria are met | Sep 21, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (CS010.X) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (2026T0375LL) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Idaho Only) (CS010ID.C) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Kansas Only) (CS010KS.03) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only) (CS010KY.06) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Nebraska Only) (CS010NE.X) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only) (CS010NJ.W) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only) (CS010NM.D) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for North Carolina Only) (CSNCT0375.06) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Ohio Only) (CS010OH.E) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Pennsylvania Only) (CS010PA.V) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Breast Imaging for Screening and Diagnosing Cancer (for Tennessee Only) (CS010TN.W) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Outpatient Radiology Procedures for EviCore Arrangement (for Oxford Only) (RADIOLOGY) Dates of Service | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Radiologic Diagnostic Procedures (MMP076.18) 3D Rendering | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in CO.
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.