96105 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 96105

14 of 14 payer prior-auth lists that name 96105 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Humana, Molina Healthcare of California, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of IllinoisBlue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)ILprior auth requiredeviCore-managedJan 1, 2025Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HumanaHumana D-SNP (IN)INprior auth requiredJan 1, 2027*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
HumanaHumana Healthy HorizonsFLprior auth requiredJan 1, 20271102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List
HumanaHumana Healthy HorizonsINprior auth requiredJan 1, 20271 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredState exceptionApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
UnitedHealthcare Community PlanNew Jersey FamilyCareNJprior auth requiredOct 1, 2026Prior 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 PlanNew Mexico Turquoise CareNMprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth requiredJul 1, 2017Prior 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 PlanTexas STARTXprior auth requiredJul 1, 2017Prior 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 PlanTexas STAR KidsTXprior auth requiredJul 1, 2017Prior 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 PlanTexas STAR+PLUSTXprior auth requiredJul 1, 2017Prior 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 PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJul 1, 2017Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U

Payer coverage policies that name 96105

96105 appears in 13 coverage policies from Aetna, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaAttention Deficit/Hyperactivity Disorder (0426)
EEG theta/beta power ratio, Gut microbiota profile, polygenic risk score, evaluation of kynurenine pathway		not coveredJul 7, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (MP.026.27)listed, no stanceJul 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (CS164.M)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only) (CS164FL.N)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Idaho Only) (CS164ID.C)listed, no stanceSep 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Kentucky Only) (CS164KY.10)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Nebraska Only) (CS164NE.K)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only) (CS164NJ.H)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Mexico Only) (CS164NM.C)listed, no stanceNov 1, 2025payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for North Carolina Only) (CSNC.MP.164.05)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Ohio Only) (CS164OH.D)listed, no stanceNov 1, 2025payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Pennsylvania Only) (CS164PA.E)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) – Site of Service (for Florida Only) (CS161FL.M)listed, no stanceJun 1, 2026payer document

Recent prior-auth changes

  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
  • Jan 1, 2026: PA removed, Humana
  • Apr 1, 2023: PA removed, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in ND.

  • AZ: $99.72 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025
  • CO: $79.79 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $75.59 (physician, non-facility), effective Jan 1, 2026
  • IL: $64.48 (practitioner), effective Apr 1, 2024
  • IN: $76.55 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $43.87 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $71.03 (behavioral_health, billed with AF/AM), effective Jul 15, 2026
  • LA: $77.89 (professional), effective Jul 1, 2025
  • MA: $72.97 (physician_medicine), effective May 1, 2024
  • ND: $108.14 (physician), effective Aug 1, 2026
  • NE: $103.64 (physician, non-facility), effective Jul 1, 2026
  • NY: $151.50 (ordered_ambulatory), effective Jul 24, 2026
  • OH: $50.01 (physician), effective Jan 1, 2024
  • OK: $86.94 (physician, non-facility), effective Jul 1, 2026
  • TX: $77.52 (physician, Physician, facility), effective Sep 1, 2023
  • VA: $84.20 (medical), effective Jul 1, 2026
  • VT: $81.60 (outpatient_hospital_opps), effective Feb 1, 2026
  • WY: $83.98 (professional), effective Jul 1, 2026

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.