97607 CPT® code: payer coverage and prior authorization2 of 2 payer prior-auth lists that name 97607 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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) |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
97607 appears in 34 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, Capital Blue Cross, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | 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 | Chiropractic Services (0107) | listed, no stance (range 97010-97799) | Apr 7, 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 | Home Health Aides (0218) | listed, no stance (range 97010-97799) | Sep 10, 2026 | payer document |
| Aetna | Knee Arthroplasty (0660) | listed, no stance (range 97010-97799) | Oct 8, 2026 | payer document |
| Aetna | Negative Pressure Wound Therapy (0334) | not covered | Jun 8, 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 | Vasectomy Procedures and Chronic Scrotal Content Pain (0027) | listed, no stance (range 97010-97799) | Jan 27, 2026 | payer document |
| Aetna | Wound Care: Home or Outpatient Setting (1054) | listed, no stance (range 97597-97610) | Dec 23, 2025 | payer document |
| Anthem | Vacuum Assisted Wound Therapy in the Outpatient Setting (CG-DME-48) | covered if criteria are met | Aug 13, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Negative Pressure Wound Therapy | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Disposable Negative Pressure Wound Therapy MEDICAL COVERAGE POLICY | 2 | not covered | Jul 1, 2026 | payer document |
| Blue Cross Blue Shield of Massachusetts | Negative Pressure Wound Therapy in the Outpatient Setting (543) | unproven / investigational | payer document | |
| Blue Cross NC | Topical Negative Pressure Therapy for Wounds | listed, no stance | Apr 1, 2026 | payer document |
| Blue Shield of California | Negative Pressure Wound Therapy in the Outpatient Setting (1.01.16) | listed, no stance | payer document | |
| Capital Blue Cross | Negative Pressure Wound Therapy in the Outpatient Setting (MP 4.004) Procedure codes | unproven / investigational | Jun 1, 2026 | payer document |
| Cigna | Negative Pressure Wound Therapy/Vacuum Assisted Closure (VAC) for Nonhealing Wounds (0064) | not covered | May 15, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Negative Pressure Wound Therapy in the Outpatient Setting (DME101.036) | listed, no stance | May 1, 2026 | payer document |
| Premera Blue Cross | Negative Pressure Wound Therapy (NPWT) Devices (1.01.508) Page | 5 of 24 | ∞ | listed, no stance | May 12, 2026 | payer document |
| Regence | Negative Pressure Wound Therapy in the Outpatient Setting (Durable Medical Equipment 42) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (2026T0594O) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (CS157.M) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Idaho Only) (CS157ID.D) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Kansas Only) (CS157KS.02) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Kentucky Only) (CS157KY.11) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Nebraska Only) (CS157NE.N) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for New Jersey Only) (CS157NJ.I) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for New Mexico Only) (CS157NM.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for North Carolina Only) (CSNCT0594.07) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Ohio Only) (CS157OH.E) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Pennsylvania Only) (CS157PA.K) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Negative Pressure Wound Therapy (for Tennessee Only) (CS157TN.K) | listed, no stance | Jul 1, 2026 | payer document |
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.