`81402` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 81402

79 of 81 payer prior-auth lists that name 81402 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, 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 Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, 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 under conditions	Only for testing unaffected individuals or carrier screening	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 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)
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2027	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Apr 10, 2026	Master Precertification List (For Health Care Providers)
Cigna	Laboratory Management	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Cigna	Laboratory Management	All	prior auth required		Oct 1, 2026	Cigna Lab Codes (title from file name)
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 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 (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana 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	FL	prior auth required		Jan 1, 2027	1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization 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	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
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
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
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 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	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 Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
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 Nevada	Medicaid	NV	prior auth required		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 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 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
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	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 Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange 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	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
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		Feb 1, 2019	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		Feb 1, 2019	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 under conditions	Prior authorization is only required for these codes with DX codes.	Feb 1, 2019	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		Feb 1, 2019	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
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth required		Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 81402

81402 appears in 27 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy (0227)	listed, no stance	Apr 14, 2026	payer document
Aetna	Cardiovascular Disease Risk Tests (0381)	listed, no stance (range 81400-81408)	Aug 25, 2026	payer document
Aetna	Genetic Testing (0140)	listed, no stance (range 81400-81408)	Aug 18, 2026	payer document
Aetna	HIV Drug Susceptibility and Resistance Tests (0316)	covered if criteria are met (range 81400-81408)	May 21, 2026	payer document
Aetna	Organ Prolapse: Selected Procedures (0858)	not covered (range 81400-81479)	Dec 24, 2025	payer document
Aetna	Pharmacogenetic and Pharmacodynamic Testing (0715)	listed, no stance (range 81400-81408)	Oct 8, 2026	payer document
Aetna	Polymerase Chain Reaction Testing: Selected Indications (0650)	covered if criteria are met (range 81400-81408)	Sep 10, 2026	payer document
Aetna	Recurrent Pregnancy Loss (0348)	covered if criteria are met (range 81402-81408)	Jun 23, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Genetic Testing (L.2.04.409)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Germline And Somatic Biomarker Testing Including Liquid Biopsy For Targeted Treatment In Breast Cancer Brca1 Brca2 Pik3ca Ki67 Ret Braf Esr1 Ntrk (A.2.04.151)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Jak2 Mpl And Calr Testing For Myeloproliferative Neoplasms	covered if criteria are met		payer document
Blue Cross NC	General Genetic Testing, Germline Disorders AHS - M2145	listed, no stance	Jan 1, 2026	payer document
Blue Cross NC	General Genetic Testing, Somatic Disorders AHS - M2146	listed, no stance	Jan 1, 2026	payer document
Blue Cross NC	Genetic Markers for Assessing Risk of Cardiovascular Disease AHS - M2180	listed, no stance	Jul 1, 2025	payer document
Blue Shield of California	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) (2.04.141)	listed, no stance		payer document
Blue Shield of California	General Approach to Evaluating the Utility of Genetic Panels (2.04.92)	listed, no stance		payer document
Blue Shield of California	\| General Approach to Genetic Testing (2.04.91)	listed, no stance		payer document
Blue Shield of California	\| Preimplantation Genetic Testing (4.02.05)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	General Genetic Testing, Germline Disorders (CAM 166)	listed, no stance	Jan 1, 2026	payer document
BlueCross BlueShield of South Carolina	Genetic Markers for Assessing Risk of Cardiovascular Disease (CAM 357)	listed, no stance	Jul 1, 2026	payer document
Regence	Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (Genetic Testing 10)	listed, no stance	Jun 1, 2026	payer document
Regence	Evaluating the Utility of Genetic Panels (Genetic Testing 64)	listed, no stance	Jun 1, 2026	payer document
Regence	Expanded Molecular Testing of Cancers to Select Targeted Therapies (Genetic Testing 83)	listed, no stance	Jun 1, 2026	payer document
Regence	Genetic Testing for Myeloid Neoplasms and Leukemia (Genetic Testing 59)	listed, no stance	Apr 1, 2026	payer document
Regence	Genetic and Molecular Diagnostic Testing (Genetic Testing 20)	listed, no stance (range 81370-81408)	Apr 1, 2025	payer document
Regence	Reproductive Carrier Screening for Genetic Diseases (Genetic Testing 81)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Tier 2 Molecular Pathology Procedures (MMP381.26)	listed, no stance	Sep 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: PA removed, UnitedHealthcare Community Plan
Jul 1, 2025: PA removed, UnitedHealthcare Community Plan
Jul 1, 2025: PA added, uhc:pa:summary-of-changes
Jul 1, 2025: PA added, uhc:pa:summary-of-changes
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Jan 1, 2025: PA removed, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in CO, MS, ND, VA, VT, WA, WV, WY.

AZ: $150.33 (lab), effective Oct 1, 2026
CO: $150.33 (lab_cdl), effective Oct 1, 2025
FL: $82.15 (lab_independent, non-facility), effective Jan 1, 2026
IL: $105.23 (practitioner), effective Apr 1, 2024
IN: $127.78 (professional, Advanced Practice Nurse (85%), non-facility), effective Jul 1, 2024
KS: $172.55 (default, Exempt Physician), effective Jan 1, 2013
KY: $150.33 (lab), effective Jan 1, 2026
MS: $135.30 (comprehensive), effective Jul 1, 2026
ND: $150.33 (physician), effective Aug 1, 2026
NE: $150.33 (lab), effective Jul 1, 2026
OH: $112.75 (lab), effective Apr 1, 2019
OK: $133.72 (physician, non-facility), effective Jul 1, 2026
VA: $150.33 (medical), effective Jan 1, 2018
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $120.26 (physician, facility), effective Jul 1, 2026
WY: $135.30 (professional), effective Apr 1, 2025

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.

81402 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 81402

Payer coverage policies that name 81402

Recent prior-auth changes

Medicaid fee-for-service

`81402` CPT® code: payer coverage and prior authorization