`96139` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 96139

38 of 41 payer prior-auth lists that name 96139 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Blue Shield of California, 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, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Rocky Mountain Health Plans, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California	Blue Shield Medicare	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield Medicare
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
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)
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 (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 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
Humana	Humana Healthy Horizons	LA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
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
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth under conditions	PA after 4 units	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 under conditions	PA after 4 units	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 California	Medicaid	CA	prior auth required	State exception	Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
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 Iowa	Medicaid	IA	prior auth required	Prior auth required after initial 4 hours of testing	Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
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	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required	*PA required after initial 4 hours of testing	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	*PA required after initial 4 hours of testing	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	Prior Auth required after initial 4 hours of testing per calendar year	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
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
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 Community Plan	Texas STAR	TX	prior auth required		Apr 1, 2026	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 required		Apr 1, 2026	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		Apr 1, 2026	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 Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name 96139

96139 appears in 12 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Attention Deficit/Hyperactivity Disorder (0426)	covered if criteria are met	Jul 7, 2026	payer document
Aetna	Autism Spectrum Disorders (0648)	covered if criteria are met (range 96138-96139)	Oct 2, 2025	payer document
Aetna	Eating Disorders (0511)	covered if criteria are met (range 96138-96139)	Aug 4, 2026	payer document
Aetna	Neuropsychological and Psychological Testing (0158)	covered if criteria are met (range 96138-96139)	Mar 20, 2026	payer document
Aetna	Onasemnogene Abeparvovec (Zolgensma and Itvisma) (0953)	listed, no stance	Aug 10, 2026	payer document
Aetna	Premenstrual Syndrome and Premenstrual Dysphoric Disorder (0512)	covered if criteria are met (range 96138-96139)	Aug 5, 2026	payer document
Blue Cross & Blue Shield of Rhode Island	Psychological and Neuropsychological Testing	listed, no stance (range 96136-96139)	Jun 12, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Neuropsychological and Psychological Testing (151)	listed, no stance		payer document
Blue Shield of California	BSC2.06 \| Neuropsychological Testing	listed, no stance		payer document
Centene	Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124)	covered if criteria are met	Mar 1, 2024	payer document
Centene	Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124)	covered if criteria are met	Feb 1, 2022	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Medical Policies Moving to MCG Guidelines Testing \| 96130, 96131, 96132, 96133, \| Psychological Testing B-	listed, no stance	Jan 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Apr 1, 2026: PA added, UnitedHealthcare Community Plan
Apr 1, 2026: PA added, UnitedHealthcare Community Plan
Apr 1, 2026: PA added, UnitedHealthcare Community Plan
Mar 1, 2026: PA added, Rocky Mountain Health Plans
Mar 1, 2026: PA added, Rocky Mountain Health Plans
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Feb 19, 2025: PA removed, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in IN.

AZ: $35.86 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025
CO: $18.87 (chp_plus_behavioral), effective Jul 1, 2026
IN: $26.25 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $23.50 (default, Mid Level Practitioner), effective Aug 1, 2024
KY: $23.61 (behavioral_health, billed with AF/AM), effective Jul 15, 2026
LA: $21.16 (specialized_behavioral_health, Medical Psychologist), effective Jan 1, 2026
MA: $27.79 (physician_medicine), effective May 1, 2024
ND: $39.80 (physician), effective Aug 1, 2026
NE: $0.00 (behavioral_health, Advanced Practice Registered Nurse (APRN)), effective Jul 1, 2025
NY: $21.08 (physician_medicine, facility), effective Jul 1, 2026
OK: $29.60 (physician, non-facility), effective Jul 1, 2026
VA: $36.19 (medical, facility), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $22.36 (mental_health_services, facility), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 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.

96139 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 96139

Payer coverage policies that name 96139

Recent prior-auth changes

Medicaid fee-for-service

`96139` CPT® code: payer coverage and prior authorization