78428 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 78428

15 of 22 payer prior-auth lists that name 78428 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Rocky Mountain Health Plans.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of CaliforniaMedicare AdvantageCAprior auth requiredJul 1, 2021Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of FloridaMedicare AdvantageFLprior auth requiredvendor review only eviCore in IL/MI/OH/NY/WIApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of IdahoMedicare AdvantageIDprior auth requiredvendor review only eviCore in IL/MI/OH/NY/WIApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of IllinoisMedicaidILprior auth requiredApr 1, 2023Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of MichiganExchangeMIprior auth requiredContact eviCore for PAJul 1, 2021Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of MichiganMedicare AdvantageMIprior auth requiredadults via EvolentJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of MichiganMedicaidMIprior auth under conditionsadults via Evolent; no PA for pediatricsJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth under conditionsno PA under 18Oct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth under conditionsno PA under 18Oct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of TexasExchangeTXprior auth requiredJul 1, 2021Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of UtahMedicare AdvantageUTprior auth requiredvendor review only eviCore in IL/MI/OH/NY/WIApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of WashingtonMedicare AdvantageWAprior auth requiredvendor review only eviCore in IL/MI/OH/NY/WIApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
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

Payer coverage policies that name 78428

78428 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaMagnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI (0520)listed, no stance (range 78414-78499)Aug 20, 2026payer document

Recent prior-auth changes

  • Mar 1, 2025: PA removed, Rocky Mountain Health Plans
  • Mar 1, 2025: PA removed, Rocky Mountain Health Plans
  • Jul 1, 2024: conditions changed, Molina Healthcare of Illinois
  • Jan 1, 2024: conditions changed, Molina Healthcare of Michigan
  • Jun 1, 2023: PA removed, Blue Shield of California Promise Health Plan
  • Jan 1, 2023: PA removed, Molina Healthcare of Ohio
  • Oct 1, 2021: PA removed, Molina Healthcare of Wisconsin
  • Oct 1, 2021: PA removed, Molina Healthcare, Inc. (national grid)

Medicaid fee-for-service

  • AZ: $150.78 (asc), effective Oct 1, 2026
  • CO: $83.61 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $100.26 (radiology), effective Jan 1, 2026
  • IL: $111.24 (practitioner), effective Apr 1, 2024
  • IN: $28.44 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $22.18 (default, Exempt Physician), effective Jan 1, 2024
  • KY: $215.08 (asc), effective Jan 1, 2026
  • MA: $111.95 (physician_radiology), effective May 1, 2024
  • MS: $173.41 (comprehensive, facility), effective Oct 1, 2025
  • ND: $152.07 (physician), effective Aug 1, 2026
  • NE: $54.01 (physician, non-facility), effective Jul 1, 2026
  • OH: $130.50 (physician), effective Jan 1, 2024
  • OK: $113.52 (physician, non-facility), effective Jul 1, 2026
  • TX: $506.31 (hospital_outpatient_imaging_services, Rural Hospitals), effective Mar 1, 2026
  • VA: $117.77 (medical), effective Jul 1, 2026
  • VT: $310.41 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $20.83 (physician, facility), effective Jul 1, 2026
  • WY: $176.79 (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.