77522 CPT® code: payer coverage and prior authorization107 of 107 payer prior-auth lists that name 77522 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, and others.
| 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) | Federal Employee Program (FEP) | AZ | prior auth required | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | eviCore-delegated groups | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Other groups: AZ Blue | 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 | Commercial | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Medicare Advantage | All | prior auth required | 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 | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Radiation Oncology | All | prior auth required | Mar 7, 2026 | Cigna Commercial Radiation Oncology Code List | |
| Cigna | Radiation Oncology | All | prior auth required | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Dec 31, 2023 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Jan 1, 2024 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 | |
| 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 Healthy Horizons | OH | prior auth required | Jan 1, 2027 | 555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Jan 1, 2027 | Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization 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 Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| 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 California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | 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 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 Mississippi | Medicaid | MS | prior auth required | cancer dx via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | cancer dx via NCH | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| 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 Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | cancer dx via Evolent | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 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 | 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 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 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 West commercial plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | KanCare | KS | prior auth required | Oct 1, 2026 | Prior authorization requirements for Kansas Medicaid Effective October 1, 2026 |
77522 appears in 43 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Centene, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Age-Related Macular Degeneration (0765) | not covered | Jan 14, 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 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 | Proton Beam, Neutron Beam, and Carbon Ion Radiotherapy (0270) | covered if criteria are met | Apr 14, 2026 | 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 | Chargedparticle Proton Or Helium Ion Radiotherapy For Neoplastic Conditions | covered if criteria are met | payer document | |
| Blue Cross NC | Proton Beam Therapy | listed, no stance | May 1, 2026 | payer document |
| Centene | Proton and Neutron Beam Therapies (CP.MP.70) | covered if criteria are met | Nov 1, 2025 | payer document |
| Regence | Charged-Particle (Proton) Radiotherapy (Medicine 49) | listed, no stance | Aug 1, 2025 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (2026T0407HH) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Intensity-Modulated Radiation Therapy (CS064.T) | listed, no stance | May 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 | Proton Beam Radiation Therapy (2026T0132MM) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (CS105.U) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Idaho Only) (CS105ID.C) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Kansas Only) (CS105KS.03) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Kentucky Only) (CS105KY.11) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Nebraska Only) (CS105NE.U) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for New Jersey Only) (CS105NJ.R) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for New Mexico Only) (CS105NM.D) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Ohio Only) (CS105OH.E) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Pennsylvania Only) (CS105PA.U) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Proton Beam Radiation Therapy (for Tennessee Only) (CS105TN.T) | listed, no stance | May 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 (CS179.H) | listed, no stance | Jun 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) Proton Beam Therapy (PBT) | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in CO, FL, VA.
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.