97130 CPT® code: payer coverage and prior authorization64 of 64 payer prior-auth lists that name 97130 require prior authorization or set conditions: 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, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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) | 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 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 | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| 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 | 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 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 Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | 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 | 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 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 | 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 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 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 | Progress notes and updated Plan of Care is required with submission for additional visits | 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 | Progress notes and updated Plan of Care is required with submission for additional visits | 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 | Progress notes and updated Plan of Care is required with submission for additional visits | 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 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 | Participating Providers: Initial evaluation does not require prior authorization | Apr 1, 2020 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Participating Providers: Initial evaluation does not require prior authorization | Apr 1, 2020 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth under conditions | PA after 12 visits | Apr 1, 2020 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| Molina Healthcare of Utah | Utah state exceptions (exceptions only) | UT | prior auth required | State exception; Benefit limit is 20 visits for PT/OT/ST per year | Jan 1, 2025 | Utah code/benefit exceptions (Marketplace), 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 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 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 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 | |
| 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 | State exception; 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 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 | 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 | 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 |
97130 appears in 44 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, 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), UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Attention Deficit/Hyperactivity Disorder (0426) EEG theta/beta power ratio, Gut microbiota profile, polygenic risk score, evaluation of kynurenine pathway | not covered | Jul 7, 2026 | payer document |
| Aetna | Autism Spectrum Disorders (0648) | listed, no stance (range 97010-97546) | Oct 2, 2025 | payer document |
| Aetna | Autism Spectrum Disorders (0648) | not covered | Oct 2, 2025 | payer document |
| Aetna | Back Pain - Invasive Procedures (0016) | listed, no stance (range 97010-97763) | 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 97110-97130) | Oct 6, 2026 | payer document |
| Aetna | Back Pain - Invasive Procedures (0016) | listed, no stance (range 97010-97799) | Oct 6, 2026 | payer document |
| Aetna | Burn Garments (0062) | listed, no stance (range 97110-97546) | 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 | Cognitive Rehabilitation (0214) | covered if criteria are met | Apr 21, 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 97110-97140) | Jun 30, 2026 | payer document |
| Aetna | Early Intervention Programs (0444) | listed, no stance (range 97110-97546) | Jul 1, 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 97110-97546) | Sep 18, 2026 | payer document |
| Aetna | Knee Arthroplasty (0660) | listed, no stance (range 97010-97799) | Oct 8, 2026 | payer document |
| Aetna | Near-Infrared (NIR) Spectroscopy (0796) | listed, no stance | Nov 19, 2025 | payer document |
| Aetna | Physical Therapy (0325) | covered if criteria are met | Jun 2, 2026 | payer document |
| Aetna | Spinal Surgery: Laminectomy and Fusion (0743) | listed, no stance (range 97110-97546) | Jul 30, 2026 | payer document |
| Aetna | Standing Frames, Tables, and Transfer Boards (0481) | listed, no stance (range 97001-97763) | Jul 2, 2026 | payer document |
| Aetna | Temporomandibular Disorders (0028) | not covered | Mar 12, 2026 | payer document |
| Aetna | Tinnitus Treatments (0406) | covered if criteria are met | Jul 10, 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 97110-97139) | Nov 12, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Cognitive Rehabilitation | covered if criteria are met | 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 Blue Shield of Massachusetts | Outpatient Cognitive Rehabilitation (660) | listed, no stance | payer document | |
| Blue Shield of California | | Cognitive Rehabilitation (8.03.10) | listed, no stance | payer document | |
| Centene | Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.MP.124) | not covered | Feb 1, 2022 | payer document |
| Centene | Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124) | not covered | Mar 1, 2024 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Cognitive Rehabilitation (THE803.019) | listed, no stance | Jan 1, 2026 | 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 |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (CS020.T) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (2026T0144II) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Idaho Only) (CS020ID.D) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Kentucky Only) (CS020KY.09) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Nebraska Only) (CS020NE.T) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for New Jersey Only) (CS020NJ.P) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for New Mexico Only) (CS020NM.D) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Ohio Only) (CS020OH.D) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Pennsylvania Only) (CS020PA.T) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cognitive Rehabilitation and Coma Stimulation (for Tennessee Only) (CS020TN.U) | listed, no stance | Aug 1, 2026 | payer document |
Prior authorization required or conditional in CO, IN, ND.
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.