77412 CPT® code: payer coverage and prior authorization56 of 74 payer prior-auth lists that name 77412 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Ohio, Molina Healthcare of Texas, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
| 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) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | eviCore-delegated groups only | 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 | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Aetna | Commercial | All | prior auth under conditions | HMO-based or fully insured Commercial plans only; Not required for Student Health or Allina Health | Aetna plans; Not required inpatient, in the ER or in observation | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Medicare Advantage | All | prior auth required | Not required for Student Health or Allina Health | Aetna plans; Not required inpatient, in the ER or in observation; Florida Medicare members go to Evolent, not eviCore | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| 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) |
| Cigna | Radiation Oncology | All | prior auth required | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| Cigna | Radiation Oncology | All | prior auth required | Mar 7, 2026 | Cigna Commercial Radiation Oncology Code List | |
| 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) |
| 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) |
| 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 | State exception | 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 Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| 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 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 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| 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 Texas | Exchange | TX | prior auth required | Jul 1, 2021 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth required | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 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 | |
| Surest | Surest health plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 | |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 | |
| 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 | UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP) | All | prior auth required | Excluded plans: Erickson Advantage and Massachusetts DSNP (includes MA SCO OneCare) | Oct 1, 2026 | UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth under conditions | only with dx C34.00, C34.01, C34.02, C34.10, C34.11, C34.12 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Louisiana Medicaid (Healthy Louisiana) | LA | prior auth required | Jan 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana | |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 | |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth under conditions | only with dx C34.00, C34.01, C34.02, C34.10, C34.11, C34.12 | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth under conditions | only with dx C34.00, C34.01, C34.02, C34.10, C34.11, C34.12 | Apr 1, 2025 | Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | New Jersey FamilyCare | NJ | prior auth required | Oct 1, 2026 | Prior 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 Plan | New Mexico Turquoise Care | NM | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Ohio Medicaid | OH | prior auth under conditions | only with dx C34.00, C34.01, C34.02, C34.10, C34.11, C34.12 | Nov 1, 2025 | Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan |
| UnitedHealthcare Community Plan | Rhode Island Medicaid | RI | prior auth required | May 1, 2026 | Prior 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 Plan | UnitedHealthcare Community Plan of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 | |
| UnitedHealthcare Community Plan | Virginia Cardinal Care LTSS | VA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Virginia Cardinal Care Medicaid | VA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth required | Oct 1, 2026 | Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023 | |
| UnitedHealthcare Community Plan | Wisconsin BadgerCare Plus and Medicaid SSI | WI | prior auth required | Sep 1, 2026 | Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community |
77412 appears in 50 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Centene, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Antiemetic Therapy (0724) | listed, no stance (range 77371-77425) | Jul 17, 2026 | payer document |
| Aetna | Breast Reduction Surgery and Gynecomastia Surgery (0017) | not covered (range 77402-77417) | Mar 12, 2026 | payer document |
| Aetna | Cardiac Computed Tomography (CT), Coronary CT Angiography, Calcium Scoring and CT Fractional Flow Reserve (0228) | listed, no stance (range 77402-77417) | Jul 21, 2026 | payer document |
| Aetna | Cemiplimab-rwlc (Libtayo) (0942) | listed, no stance (range 77261-77799) | Jun 12, 2026 | payer document |
| Aetna | Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082) | listed, no stance (range 77401-77412) | Mar 18, 2026 | payer document |
| Aetna | Enfortumab Vedotin-ejfv (Padcev) (0967) | listed, no stance (range 77399-77417) | Oct 9, 2026 | payer document |
| Aetna | Glaucoma Surgery (0484) | not covered (range 77402-77412) | Jul 14, 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 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 | Intensity Modulated Radiation Therapy (0590) | covered if criteria are met | Sep 8, 2026 | payer document |
| Aetna | Intraoperative Radiation Therapy (IORT) (0721) | listed, no stance (range 77401-77417) | Oct 20, 2025 | payer document |
| Aetna | Irinotecan Liposome Injection (Onivyde) (0902) | listed, no stance (range 77401-77417) | Feb 24, 2026 | payer document |
| Aetna | Knee Arthroplasty (0660) | not covered (range 77402-77412) | Oct 8, 2026 | payer document |
| Aetna | Lyme Disease and other Tick-Borne Diseases (0215) Alpha lipoic acid or “Healing” Detox Drips, testing for other tick-borne diseases from other organisms, antibiotic augmented thermo-eradication (AAT) therapy | not covered (range 77402-77417) | Jul 21, 2026 | payer document |
| Aetna | Pembrolizumab Products (Keytruda and Keytruda Qlex) (0890) | listed, no stance (range 77402-77417) | Jul 14, 2026 | payer document |
| Aetna | Plantar Fasciitis Treatments (0235) | not covered (range 77401-77417) | Apr 27, 2026 | payer document |
| Aetna | Radiation Treatment for Selected Nononcologic Indications (0551) | covered if criteria are met (range 77402-77417) | Jul 30, 2026 | payer document |
| Aetna | Strontium Chloride Sr-89 (0361) | listed, no stance (range 77261-77525) | Jan 9, 2026 | payer document |
| Aetna | Transperineal Placement of Biodegradable Material for Prostate Cancer (0926) | listed, no stance (range 77401-77417) | Dec 23, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Lowdose Radiotherapy For Nononcologic Indications (A.7.01.179) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Stereotactic Radiosurgery And Stereotactic Body Radiotherapy | covered if criteria are met | payer document | |
| Blue Cross NC | Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Intensity Modulated Radiation Therapy (IMRT) of Head and Neck | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Intensity Modulated Radiation Therapy (IMRT) of the Chest | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Intensity Modulated Radiation Therapy (IMRT) of the Prostate | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System | listed, no stance | May 1, 2026 | payer document |
| Centene | Radiation Therapy for Skin Cancer (CP.MP.251) | covered if criteria are met | Aug 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (CS064.T) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (2026T0407HH) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Idaho Only) (CS064ID.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Kansas Only) (CS064KS.02) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Kentucky Only) (CS064KY.09) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Nebraska Only) (CS064NE.T) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for New Jersey Only) (CS064NJ.Q) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for New Mexico Only) (CS064NM.C) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for North Carolina Only) (CSNCT0407.05) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Ohio Only) (CS064OH.D) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Pennsylvania Only) (CS064PA.S) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (for Tennessee Only) (CS064TN.S) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (CS179.H) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (2026T0613L) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Idaho Only) (CS179ID.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kansas Only) (CS179KS.02) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kentucky Only) (CS179KY.04) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey Only) (CS179NJ.E) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Mexico Only) (CS179NM.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Ohio Only) (CS179OH.E) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Radiation and Oncologic Procedures (MMP077.17) Radiation Treatment Delivery; Level 1, 2, 3 (When Reported for 2D/3D) | listed, no stance | Sep 1, 2026 | payer document |
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.