77417 CPT® code: payer coverage and prior authorization7 of 14 payer prior-auth lists that name 77417 require prior authorization or set conditions: Cigna, HealthSpring, 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 | |
| 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 |
77417 appears in 16 coverage policies from Aetna.
| 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 | Enfortumab Vedotin-ejfv (Padcev) (0967) | listed, no stance (range 77399-77417) | Oct 9, 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 | 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 | 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 |
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.