77439 CPT® code: payer coverage and prior authorization21 of 23 payer prior-auth lists that name 77439 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, Humana, Molina Healthcare of California, Molina Healthcare of Michigan.
| 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 | Jan 1, 2026 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2026 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2026 | Master Precertification List (For Health Care Providers) |
| Cigna | Radiation Oncology | All | prior auth under conditions | Add-on code: requested with the primary procedure | Jan 1, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| Cigna | Radiation Oncology | All | prior auth required | Jan 1, 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) |
| 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 | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| 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 Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
77439 appears in 24 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Centene, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | 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 77427-77499) | 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 77427-77499) | Oct 20, 2025 | 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 77436-77439) | Jul 21, 2026 | payer document |
| Aetna | Obsolete and Unreliable Tests and Procedures (0438) | not covered | Jul 16, 2026 | payer document |
| Aetna | Pembrolizumab Products (Keytruda and Keytruda Qlex) (0890) | listed, no stance (range 77427-77470) | Jul 14, 2026 | payer document |
| Aetna | Radiation Treatment for Selected Nononcologic Indications (0551) | covered if criteria are met | Jul 30, 2026 | payer document |
| Aetna | Strontium Chloride Sr-89 (0361) | listed, no stance (range 77261-77525) | Jan 9, 2026 | payer document |
| Aetna | Ultrasound Guidance – Selected Indications (0952) | not covered | Apr 27, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Electronic Brachytherapy For Nonmelanoma Skin Cancer | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Electronic Brachytherapy for Nonmelanoma Skin Cancer sad MEDICAL COVERAGE POLICY | 2 | not covered | Aug 20, 2025 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Superficial Radiation Therapy and Electronic Brachytherapy for Nonmelanoma Skin Cancer sad | not covered | Sep 16, 2026 | payer document |
| Blue Cross NC | Electronic Brachytherapy for Nonmelanoma Skin Cancer | listed, no stance | May 1, 2026 | payer document |
| Blue Cross NC | Radiation Therapy Services | listed, no stance | Nov 1, 2025 | payer document |
| Centene | Radiation Therapy for Skin Cancer (CP.MP.251) | covered if criteria are met | Aug 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 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 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 |
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.