`97039` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 97039

66 of 66 payer prior-auth lists that name 97039 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Shield of California, CarePlus Health Plans, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, 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, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California	Blue Shield commercial	CA	prior auth under conditions	CalPERS ASO only	Sep 1, 2026	Prior Authorization List for Blue Shield
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2020	Procedure Code List, Effective 1/1/2025
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
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 (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina 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 MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
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 Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
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	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
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 Illinois	Medicaid	IL	prior auth required		Apr 1, 2023	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth under conditions	PA after 12 visits per calendar year	Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth under conditions	PA after 12 visits per calendar year	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 Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required	State exception; PA required after initial evaluation for PT/OT/ST. No PA required for initial evaluation	Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
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	Medicaid	NM	prior auth under conditions	PA after 12 visits per calendar year	Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
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	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required	Prior auth required after initial evaluation	Jul 1, 2023	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
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	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
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
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth under conditions	PA after 20 visits per calendar year	Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth under conditions	place of service 11	Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth under conditions	Age 21+; • Prior authorization required after the initial evaluation and before the initial therapy visit and is required for all ongoing therapy visits For QMB members: Occupational and physical ther	Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana Hoosier Care Connect	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana PathWays for Aging (MLTSS)	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	Age 21+; Prior authorization required for members ages 21 and older	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior 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 Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Jan 1, 2015	Prior 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 Plan	Texas STAR	TX	prior auth required		Jan 1, 2015	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		Nov 1, 2016	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		Jan 1, 2015	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 Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
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
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026

Payer coverage policies that name 97039

97039 appears in 59 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Autism Spectrum Disorders (0648)	listed, no stance (range 97010-97546)	Oct 2, 2025	payer document
Aetna	Back Pain - Invasive Procedures (0016)	listed, no stance (range 97010-97039)	Oct 6, 2026	payer document
Aetna	Back Pain - Invasive Procedures (0016)	listed, no stance (range 97010-97139)	Oct 6, 2026	payer document
Aetna	Back Pain - Invasive Procedures (0016)	listed, no stance (range 97010-97799)	Oct 6, 2026	payer document
Aetna	Back Pain - Invasive Procedures (0016)	listed, no stance (range 97010-97763)	Oct 6, 2026	payer document
Aetna	Burn Garments (0062)	listed, no stance (range 97032-97039)	Jan 15, 2026	payer document
Aetna	Chiropractic Services (0107)	listed, no stance (range 97010-97799)	Apr 7, 2026	payer document
Aetna	Chronic Pain Rehabilitation Programs (0237)	listed, no stance (range 97010-97546)	Apr 23, 2026	payer document
Aetna	Complementary and Alternative Medicine (0388)	listed, no stance	Jun 25, 2026	payer document
Aetna	Complex Regional Pain Syndrome (CRPS): Treatments (0447)	listed, no stance (range 97010-97168)	Jul 16, 2026	payer document
Aetna	Eagle's and Ernest Syndrome (0400)	listed, no stance (range 97032-97039)	Jun 30, 2026	payer document
Aetna	Electrodiagnostic Testing (0502)	listed, no stance (range 97010-97799)	Jul 29, 2026	payer document
Aetna	Functional Electrical Stimulation and Neuromuscular Electrical Stimulation (0677)	listed, no stance (range 97010-97763)	Sep 10, 2026	payer document
Aetna	Hip Arthroplasty (0287)	listed, no stance (range 97010-97546)	Sep 23, 2026	payer document
Aetna	Home Health Aides (0218)	listed, no stance (range 97010-97799)	Sep 10, 2026	payer document
Aetna	Intervertebral Disc Prostheses (0591)	listed, no stance (range 97010-97039)	Sep 18, 2026	payer document
Aetna	Knee Arthroplasty (0660)	listed, no stance (range 97010-97799)	Oct 8, 2026	payer document
Aetna	Physical Therapy (0325)	listed, no stance	Jun 2, 2026	payer document
Aetna	Standing Frames, Tables, and Transfer Boards (0481)	listed, no stance (range 97001-97763)	Jul 2, 2026	payer document
Aetna	Total Ankle Arthroplasty (0645)	listed, no stance (range 97001-97799)	Sep 14, 2026	payer document
Aetna	Transforaminal Epidural Injections (0722)	listed, no stance (range 97010-97530)	Oct 20, 2025	payer document
Aetna	Vasectomy Procedures and Chronic Scrotal Content Pain (0027)	listed, no stance (range 97010-97799)	Jan 27, 2026	payer document
Aetna	Vulvodynia and Vulvar Vestibulitis Treatments (0759)	covered if criteria are met (range 97034-97039)	Nov 12, 2025	payer document
Anthem	Mechanized Spinal Distraction Therapy (SURG.00008)	unproven / investigational	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Dry Hydromassage (L.8.01.401)	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	High Intensity Laser Therapy For Chronic Musculoskeletal Pain Conditions And Bells Palsy (A.2.01.108)	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Temporomandibular Joint Disorder	covered if criteria are met		payer document
Blue Cross & Blue Shield of Rhode Island	Dry Hydrotherapy for Chronic Pain Conditions Medicare Advantage Plans and Commercial Products	listed, no stance	Jan 7, 2026	payer document
Blue Cross & Blue Shield of Rhode Island	Physical and Occupational Services PAYMENT POLICY \| 3	covered if criteria are met	Feb 17, 2026	payer document
Blue Cross NC	Chiropractic Services	listed, no stance	Sep 1, 2025	payer document
Blue Cross NC	Rehabilitative Therapies	listed, no stance	Sep 1, 2025	payer document
Blue Shield of California	BSC8.03 \| Physical Therapy	listed, no stance		payer document
Blue Shield of California	High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy (2.01.108)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Dry Hydrotherapy for Chronic Pain Conditions (CAM 201105)	listed, no stance	Jul 1, 2026	payer document
Capital Blue Cross	Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient) (MP 8.001) Procedure Codes	unproven / investigational	Sep 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell’s Palsy (MED201.057)	listed, no stance	Oct 15, 2025	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Physical Therapy (PT) and Occupational Therapy (OT) Services (THE803.010) CPT Codes 95851, 95852, 95992, 96125, 97010, 97012, 97014, 97016, 97018,	listed, no stance	Jan 1, 2026	payer document
Regence	Low-Level Laser Therapy (Medicine 105)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (CS164.M)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (MP.026.27)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only) (CS164FL.N)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Idaho Only) (CS164ID.C)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Kentucky Only) (CS164KY.10)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Nebraska Only) (CS164NE.K)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Jersey Only) (CS164NJ.H)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for New Mexico Only) (CS164NM.C)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Ohio Only) (CS164OH.D)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Pennsylvania Only) (CS164PA.E)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) – Site of Service (for Florida Only) (CS161FL.M)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Skilled Nursing Facility, Rehabilitation, Long-Term Acute Care Hospital, and Private Duty Nursing (MMP079.19)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint (TMJ) (MMP025.14) Treatments Such as the Injection of Corticosteroid and Physical Therapy	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (CS195.J)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (2026T0079RR)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Idaho Only) (CS195ID.C)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Indiana Only) (CS195IN.06)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Kansas Only) (CS195KS.02)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Kentucky Only) (CS195KY.10)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Nebraska Only) (CS195NE.J)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for New Jersey Only) (CS195NJ.G)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Ohio Only) (CS195OH.E)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Pennsylvania Only) (CS195PA.H)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Treatment of Temporomandibular Joint Disorders (for Tennessee Only) (CS195TN.H)	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
Apr 1, 2026: conditions changed, Passport by Molina Healthcare (Kentucky)
Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jan 1, 2026: conditions changed, Molina Healthcare of Michigan
Jan 1, 2026: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in IN, KY, MS, ND, VT, WV.

AZ: $10.95 (physician, AHCCCS PT 08, facility), effective Oct 1, 2020
IN: $15.19 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $15.68 (physician, facility), effective Jan 1, 2026
MS: $9.93 (comprehensive), effective Jul 1, 2026
ND: $0.00 (physician), effective Aug 1, 2026
NE: $11.50 (physician, non-facility), effective Jul 1, 2026
VA: $7.73 (medical), effective Jul 1, 2009
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $6.12 (habilitative, facility), 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.

97039 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 97039

Payer coverage policies that name 97039

Recent prior-auth changes

Medicaid fee-for-service

`97039` CPT® code: payer coverage and prior authorization