91035 CPT® code: payer coverage and prior authorization1 of 1 payer prior-auth lists that name 91035 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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) |
91035 appears in 10 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Esophageal and Airway pH Monitoring (0667) | listed, no stance | Oct 7, 2026 | payer document |
| Aetna | Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) | listed, no stance | Oct 29, 2025 | payer document |
| Anthem | Esophageal pH Monitoring (CG-MED-02) | covered if criteria are met | Aug 13, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Esophageal Ph Monitoring | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Esophageal pH Monitoring | covered if criteria are met | Mar 4, 2026 | payer document |
| Blue Cross Blue Shield of Massachusetts | Esophageal pH Monitoring (069) | listed, no stance | payer document | |
| Blue Cross NC | Esophageal pH Monitoring | listed, no stance | Mar 1, 2026 | payer document |
| Blue Shield of California | | Esophageal pH Monitoring (2.01.20) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Esophageal pH Monitoring (CAM 20120) | listed, no stance | Jul 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Esophageal pH Monitoring (MED201.005) | 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.