`78469` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 78469

60 of 60 payer prior-auth lists that name 78469 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, 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, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth under conditions	FEP Blue Focus only	Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
Aetna	Medicare Advantage	All	prior auth required	Not required for Student Health or Allina Health \| Aetna plans	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required	Not required for Student Health or Allina Health \| Aetna plans	Oct 1, 2026	Participating provider precertification list for Aetna®
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	Cardiology Services	All	prior auth required			Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
Humana	Cardiology Services	All	prior auth required			Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
Humana	Cardiology Services	All	prior auth required			Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services
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	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
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
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
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		Apr 1, 2023	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	adults via Evolent	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 Michigan	Medicare Advantage	MI	prior auth required	adults via Evolent	Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required	adults 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	adults 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 under conditions	via NCH; PA for age over 18	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 under conditions	age under 18	Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth under conditions	via NCH; PA for age over 18	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	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
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	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 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 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	adults via Evolent	Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required	site of care: site of service reviewed	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
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 Community Plan	North Carolina Medicaid	NC	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
UnitedHealthcare Community Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth required		Nov 1, 2016	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p

Payer coverage policies that name 78469

78469 appears in 3 coverage policies from Aetna, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI (0520)	listed, no stance (range 78414-78499)	Aug 20, 2026	payer document
Aetna	Single Photon Emission Computed Tomography (SPECT) (0376)	covered if criteria are met	May 28, 2026	payer document
UnitedHealthcare	Outpatient Radiology Procedures for EviCore Arrangement (for Oxford Only) (RADIOLOGY) Dates of Service	listed, no stance	Sep 1, 2026	payer document

Recent prior-auth changes

Jul 1, 2026: PA removed, HealthSpring
May 30, 2025: PA removed, Cigna
May 30, 2025: PA removed, Cigna
Jan 1, 2023: conditions changed, Molina Healthcare of Ohio

Medicaid fee-for-service

Prior authorization required or conditional in KY, MS, NY, WA.

AZ: $279.78 (asc), effective Oct 1, 2026
CO: $172.04 (chp_plus, non-facility), effective Jul 1, 2026
FL: $32.99 (radiology), effective Jan 1, 2026
IL: $131.38 (practitioner), effective Apr 1, 2024
IN: $33.94 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $26.38 (default, Exempt Physician), effective Jan 1, 2024
KY: $292.75 (asc), effective Jan 1, 2026
LA: $67.48 (lab_radiology), effective Jul 1, 2012
MA: $31.63 (physician_radiology), effective May 1, 2024
MS: $233.21 (comprehensive, facility), effective Oct 1, 2025
ND: $46.56 (physician), effective Aug 1, 2026
NE: $326.95 (physician, non-facility), effective Jul 1, 2026
NY: $116.15 (ordered_ambulatory), effective Jul 24, 2026
OH: $176.42 (physician), effective Jan 1, 2018
OK: $134.74 (physician, non-facility), effective Jul 1, 2026
VA: $139.75 (medical), effective Jul 1, 2026
VT: $421.59 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $25.23 (physician, facility), effective Jul 1, 2026
WY: $240.12 (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.

78469 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 78469

Payer coverage policies that name 78469

Recent prior-auth changes

Medicaid fee-for-service

`78469` CPT® code: payer coverage and prior authorization