91133 CPT® code: payer coverage and prior authorization2 of 2 payer prior-auth lists that name 91133 require prior authorization or set conditions: Rocky Mountain Health Plans, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
91133 appears in 17 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Capital Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Gastrointestinal Function: Selected Tests (0396) | not covered | Jul 9, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Electrogastrography (EGG) | not covered | Jan 8, 2025 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Electrogastrography (EGG) sa | not covered | Jan 7, 2026 | payer document |
| Blue Cross NC | Electrogastrography, Cutaneous | listed, no stance | Mar 1, 2026 | payer document |
| Capital Blue Cross | Experimental and Investigational Procedures (MP 4.002) Procedure codes: Lab services | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Gastroesophageal and Gastrointestinal (GI) Services and Procedures (MMP039.19) Electrogastrography or Electroenterography | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (2026T0415II) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (CS046.T) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Idaho Only) (CS046ID.C) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Kansas Only) (CS046KS.04) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Kentucky Only) (CS046KY.12) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Nebraska Only) (CS046NE.T) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for New Jersey Only) (CS046NJ.R) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for New Mexico Only) (CS046NM.E) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Ohio Only) (CS046OH.F) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Pennsylvania Only) (CS046PA.S) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Gastrointestinal Disorders Diagnostic Procedures (for Tennessee Only) (CS046TN.S) | listed, no stance | Jul 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.