88377 CPT® code: payer coverage and prior authorization18 of 20 payer prior-auth lists that name 88377 require prior authorization or set conditions: Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, 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, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | |
| 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 | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | 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 | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | 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 |
88377 appears in 12 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, BlueCross BlueShield of South Carolina, Cigna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Cervical Cancer Screening and Diagnosis (0443) | not covered (range 88367-88377) | Jul 22, 2026 | payer document |
| Aetna | Durvalumab (Imfinzi) (0917) | listed, no stance | Sep 25, 2026 | payer document |
| Aetna | Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496) | listed, no stance | Aug 6, 2026 | payer document |
| Aetna | Trastuzumab Products (0313) | listed, no stance (range 88367-88377) | Jun 8, 2026 | payer document |
| Aetna | Tumor Markers (0352) | covered if criteria are met | Aug 25, 2026 | payer document |
| Aetna | Tumor Markers (0352) | listed, no stance (range 88367-88377) | Aug 25, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Urinary Biomarkers For Cancer Screening Diagnosis And Surveillance | unproven / investigational | payer document | |
| Blue Cross NC | Esophageal Pathology Testing AHS - M2171 | listed, no stance | Apr 1, 2026 | payer document |
| Blue Cross NC | Professional Pathology Billing Requirements AHS – R2169 | listed, no stance (range 88300-88399) | Mar 1, 2024 | payer document |
| BlueCross BlueShield of South Carolina | Esophageal Pathology Testing (CAM 242) Number | listed, no stance | Apr 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Laboratory/Pathology Services (CAM 472) | listed, no stance | Jan 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Molecular Analysis for Gliomas (CAM 337) | listed, no stance | Oct 1, 2025 | payer document |
| Cigna | Laboratory Testing Services (0604) | not covered | May 15, 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.