97167 CPT® code: payer coverage and prior authorization7 of 10 payer prior-auth lists that name 97167 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Blue Shield of California, Humana, Molina Healthcare of Texas, UnitedHealthcare Community Plan.
97167 appears in 45 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, 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 (range 97165-97168) | Jul 7, 2026 | payer document |
| Aetna | Autism Spectrum Disorders (0648) | covered if criteria are met (range 97161-97168) | Oct 2, 2025 | payer 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 97161-97168) | Oct 6, 2026 | 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 97010-97799) | Oct 6, 2026 | payer document |
| Aetna | Burn Garments (0062) | listed, no stance (range 97110-97546) | Jan 15, 2026 | payer document |
| Aetna | Burn Garments (0062) | listed, no stance (range 97161-97168) | 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 | Complex Regional Pain Syndrome (CRPS): Treatments (0447) | listed, no stance (range 97010-97168) | Jul 16, 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 | Mechanical Stretching Devices for Contracture and Joint Stiffness (0405) | listed, no stance (range 97165-97168) | Jun 30, 2026 | payer document |
| Aetna | Occupational Therapy (0250) | covered if criteria are met (range 97165-97168) | May 19, 2026 | payer document |
| Aetna | Pediatric Intensive Feeding Programs (0809) | listed, no stance (range 97161-97168) | Dec 11, 2025 | 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 | 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 | Wheelchairs and Power Operated Vehicles (Scooters) (0271) | listed, no stance (range 97165-97168) | Aug 21, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Autism Spectrum Disorders Mandate | covered if criteria are met | Apr 15, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Physical and Occupational Services | covered if criteria are met | Feb 17, 2026 | payer document |
| Blue Cross NC | Rehabilitative Therapies | listed, no stance | Sep 1, 2025 | payer document |
| BlueCross BlueShield of South Carolina | Occupational Therapy (CAM 80303) 97004 | Occupational therapy re-evaluation | listed, no stance | Jun 1, 2026 | payer document |
| Capital Blue Cross | Intensive Pediatric Feeding Programs (MP 2.079) Procedure Codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Centene | Skilled Nursing Facility Leveling (CP.MP.206) | covered if criteria are met | Aug 1, 2022 | payer document |
| Cigna | Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment (0447) | covered if criteria are met | May 15, 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 |
| Premera Blue Cross | Preventive Care Covered with written prescription | The USPSTF recommends | covered if criteria are met | Sep 21, 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) (CS164.M) | listed, no stance | Aug 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 North Carolina Only) (CSNC.MP.164.05) | listed, no stance | Aug 1, 2026 | 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 | Home Health, Skilled, and Custodial Care Services (for North Carolina Only) (CSNC.MP.022.08) | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in LA, ND, VA, WV.
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.