HCPCS Level II › C codes C9604 Perc d-e cor revasc t cabg sPercutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 2 units per day (clinical), rationale: Clinical: Data Outpatient hospital: max 2 units per day (clinical), rationale: Clinical: Data Payer policies and prior authorization for C9604 15 of 15 payer prior-auth lists that name C9604 require prior authorization or set conditions: Blue Shield of California, CarePlus Health Plans, Humana.
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 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 Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services Humana Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services Humana Cardiology Services All prior auth required Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services 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 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 Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Payer coverage policies that name C9604 C9604 appears in 3 coverage policies from Aetna, Blue Shield of California, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Drug-Eluting Stents (0621) listed, no stance (range C9604-C9605) Sep 23, 2026 payer document Blue Shield of California BSC6.02 Elective Percutaneous Coronary Intervention (PCI) listed, no stance payer document UnitedHealthcare Percutaneous Coronary Interventions (MMP235.15) listed, no stance Sep 1, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in WA.
AZ: $6142.14 (asc), effective Oct 1, 2026 IN: $0.00 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2021 ND: $0.00 (physician), effective Aug 1, 2026 TX: $258.22 (physician, Physician, facility), effective Sep 1, 2025 VT: $8963.61 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $5105.26 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.