77331 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 77331

34 of 42 payer prior-auth lists that name 77331 require prior authorization or set conditions: Cigna, HealthSpring, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsAug 1, 2012Master Precertification List (For Health Care Providers)
CignaBasic StandardAllprior auth requiredMay be delegated to eviCore for some clientsAug 1, 2012Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsAug 1, 2012Master Precertification List (For Health Care Providers)
HealthSpringMedicare AdvantageAllprior auth requiredJan 1, 20252026 Q4 Prior Authorization List
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of IllinoisMedicaidILprior auth requiredApr 1, 2023Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of MichiganMedicaidMIprior auth under conditionsadults via Evolent; no PA for pediatricsJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Neighborhood Health PartnershipNeighborhood Health PartnershipFLprior auth requiredSep 1, 2026Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health PlansOxford Health PlansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Oxford Effective October 1, 2026
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
Rocky Mountain Health PlansRocky Mountain Medicare Advantage D-SNPCOprior auth requiredFeb 1, 2025Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
SurestSurest health plansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcarePreferred Care Network and Preferred Care Partners of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcareUnitedHealthcare CommercialAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Individual Exchange plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)Allprior auth requiredExcluded plans: Erickson Advantage and Massachusetts DSNP (includes MA SCO OneCare)Oct 1, 2026UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Mid-Atlantic Health PlansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare of the River ValleyAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare of the River Valley 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 PlanMississippi CHIPMSprior auth requiredApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth requiredApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
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 PlanNew Mexico Turquoise CareNMprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth requiredNov 1, 2025Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth requiredMay 1, 2026Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
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 KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
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 77331

77331 appears in 17 coverage policies from Aetna, Blue Cross NC, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaCemiplimab-rwlc (Libtayo) (0942)listed, no stance (range 77261-77799)Jun 12, 2026payer document
AetnaGrowth Hormone (GH) and Growth Hormone Antagonists (0170)listed, no stance (range 77261-77799)Jun 26, 2026payer document
AetnaHematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496)listed, no stance (range 77261-77799)Aug 6, 2026payer document
AetnaInfertility (0327)listed, no stance (range 77261-77790)Jul 16, 2026payer document
AetnaIntraoperative Radiation Therapy (IORT) (0721)listed, no stance (range 77300-77399)Oct 20, 2025payer document
AetnaStrontium Chloride Sr-89 (0361)listed, no stance (range 77261-77525)Jan 9, 2026payer document
Blue Cross NCRadiation Therapy Serviceslisted, no stanceNov 1, 2025payer document
Blue Cross NCRadiosurgery, Stereotactic Approachlisted, no stanceMay 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (CS179.H)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (2026T0613L)listed, no stanceMar 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Idaho Only) (CS179ID.C)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kansas Only) (CS179KS.02)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kentucky Only) (CS179KY.04)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey Only) (CS179NJ.E)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Mexico Only) (CS179NM.C)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Ohio Only) (CS179OH.E)listed, no stanceJun 1, 2026payer document
UnitedHealthcareRadiation and Oncologic Procedures (MMP077.17)
Radiation Therapy Special/Associated Services		listed, no stanceSep 1, 2026payer document

Recent prior-auth changes

  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Mar 1, 2026: PA added, UnitedHealthcare Community Plan
  • Jan 1, 2026: PA added, Molina Healthcare of Michigan
  • Feb 1, 2025: PA added, Rocky Mountain Health Plans
  • Jan 1, 2025: PA added, Rocky Mountain Health Plans
  • Jan 1, 2025: PA added, Rocky Mountain Health Plans
  • Jul 1, 2024: conditions changed, Molina Healthcare of Illinois
  • Feb 1, 2024: PA removed, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

  • AZ: $10.47 (asc), effective Oct 1, 2026
  • CO: $16.40 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $32.56 (radiology), effective Jan 1, 2026
  • IN: $36.62 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $39.12 (default, Exempt Physician), effective Jan 1, 2024
  • KY: $18.67 (asc), effective Jan 1, 2026
  • LA: $51.68 (lab_radiology), effective Jul 1, 2025
  • MA: $49.35 (physician_radiology), effective May 1, 2024
  • MS: $14.75 (comprehensive, facility), effective Oct 1, 2025
  • ND: $18.47 (physician, facility), effective Aug 1, 2026
  • NE: $82.18 (physician, non-facility), effective Jul 1, 2026
  • NY: $67.47 (ordered_ambulatory), effective Jul 24, 2026
  • OH: $49.25 (physician), effective Jan 1, 2024
  • OK: $57.12 (physician, non-facility), effective Jul 1, 2026
  • VA: $16.78 (medical), effective Jul 1, 2026
  • VT: $104.36 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $27.33 (physician, facility), effective Jul 1, 2026
  • WY: $59.44 (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.