Payer policies › CPT 7729077290 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 77290 15 of 23 payer prior-auth lists that name 77290 require prior authorization or set conditions: CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan.
Payer Plan State Prior auth Conditions Since Source Cigna ACA/IFP All prior auth required May be delegated to eviCore for some clients Aug 1, 2012 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required May be delegated to eviCore for some clients Aug 1, 2012 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required May be delegated to eviCore for some clients Aug 1, 2012 Master Precertification List (For Health Care Providers) HealthSpring Medicare Advantage All prior auth required Jan 1, 2025 2026 Q4 Prior Authorization List 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 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 (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 Healthy Horizons IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . 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 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 Illinois Medicaid IL prior auth required Apr 1, 2023 Molina Healthcare of Illinois Codification Grid Q3 2026 Molina Healthcare of Michigan Medicaid MI prior auth under conditions adults via Evolent; no PA for pediatrics Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3
Payer coverage policies that name 77290 77290 appears in 13 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, BlueCross BlueShield of South Carolina, Centene.
Payer Policy Role in policy Reviewed Document Aetna Brentuximab Vedotin (Adcetris) (0823) listed, no stance (range 77261-77295) Sep 24, 2026 payer document Aetna Cemiplimab-rwlc (Libtayo) (0942) listed, no stance (range 77261-77799) Jun 12, 2026 payer document Aetna Growth Hormone (GH) and Growth Hormone Antagonists (0170) listed, no stance (range 77261-77799) Jun 26, 2026 payer document Aetna Hematopoietic Cell Transplantation for Hodgkin's Disease (0495) listed, no stance (range 77261-77295) Jul 2, 2026 payer document Aetna Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496) listed, no stance (range 77261-77799) Aug 6, 2026 payer document Aetna Infertility (0327) listed, no stance (range 77261-77790) Jul 16, 2026 payer document Aetna Intraoperative Radiation Therapy (IORT) (0721) listed, no stance (range 77261-77299) Oct 20, 2025 payer document Aetna Microwave Thermotherapy (0682) listed, no stance (range 77280-77295) Oct 15, 2025 payer document Aetna Strontium Chloride Sr-89 (0361) listed, no stance (range 77261-77525) Jan 9, 2026 payer document Blue Cross & Blue Shield of Mississippi Accelerated Breast Irradiation And Brachytherapy Boost After Breastconserving Surgery For Earlystage Breast Cancer covered if criteria are met payer document Blue Cross NC Radiation Therapy Services listed, no stance Nov 1, 2025 payer document BlueCross BlueShield of South Carolina Breast Cancer Radiation Oncology (CAM 381) listed, no stance (range 77280-77295) Apr 1, 2026 payer document Centene Radiation Therapy for Skin Cancer (CP.MP.251) covered if criteria are met Aug 1, 2026 payer document
Recent prior-auth changes Jan 1, 2026: PA added, Molina Healthcare of Michigan Oct 31, 2024: PA removed, humana:pa:commercial Jul 1, 2024: conditions changed, Molina Healthcare of Illinois Jul 1, 2024: PA removed, humana:pa:commercial Medicaid fee-for-service AZ: $113.96 (asc), effective Oct 1, 2026 CO: $67.34 (chp_plus, non-facility), effective Jul 1, 2026 FL: $279.78 (radiology), effective Jan 1, 2026 IN: $65.49 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $267.64 (default, Exempt Physician), effective Jan 1, 2024 KY: $200.91 (asc), effective Jan 1, 2026 LA: $340.31 (lab_radiology), effective Jul 1, 2025 MA: $358.46 (physician_radiology), effective May 1, 2024 MS: $157.19 (comprehensive, facility), effective Oct 1, 2025 ND: $90.49 (physician), effective Aug 1, 2026 NE: $501.91 (physician, non-facility), effective Jul 1, 2026 NY: $104.64 (ordered_ambulatory), effective Jul 24, 2026 OH: $298.59 (physician), effective Jan 1, 2024 OK: $300.67 (physician, non-facility), effective Jul 1, 2026 TX: $371.05 (miscellaneous_other_professionals_radiation_treatment_center, Miscellaneous Other Professionals - Radiation Treatment Center, facility), effective Mar 1, 2026 VA: $70.89 (medical), effective Jul 1, 2026 VT: $290.73 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $48.92 (physician, facility), effective Jul 1, 2026 WY: $165.58 (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.