78605 CPT® code: payer coverage and prior authorization12 of 12 payer prior-auth lists that name 78605 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Michigan, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | eviCore-managed | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Carelon-managed | Jan 1, 2021 | 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) |
| 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 | 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 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 Texas | Exchange | TX | prior auth required | Jul 1, 2021 | 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 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 |
| 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 |
78605 appears in 7 coverage policies from Aetna, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Attention Deficit/Hyperactivity Disorder (0426) EEG theta/beta power ratio, Gut microbiota profile, polygenic risk score, evaluation of kynurenine pathway | not covered | Jul 7, 2026 | payer document |
| Aetna | Autism Spectrum Disorders (0648) | not covered | Oct 2, 2025 | payer document |
| Aetna | Eating Disorders (0511) | not covered (range 78600-78610) | Aug 4, 2026 | payer document |
| Aetna | Tourette's Syndrome (0480) | not covered | Jul 24, 2026 | payer document |
| Centene | Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124) | not covered | Feb 1, 2022 | payer document |
| Centene | Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124) | not covered | Mar 1, 2024 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Medical Policies Moving to MCG Guidelines Spectrum Disorders (ASD) | 70460, 70470, 70496, 70551, | Disorders – Gene Panels | listed, no stance | Jan 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.