E0791 Parenteral infusion pump staParenteral infusion pump, stationary, single or multi-channel
6 of 6 payer prior-auth lists that name E0791 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Humana, Medicare, Molina Complete Care (Virginia), UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Medicare | DMEPOS Master List (items potentially subject to PA) | All | prior auth under conditions | On the Master List; PA only if CMS selects it for the Required List | Jul 30, 2026 | Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements |
| 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) |
| Humana | Humana Healthy Horizons | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| Molina Complete Care (Virginia) | Virginia state exceptions to the national Medicaid grid (exceptions only) | VA | prior auth required | State exception | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | State exception | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 |
| 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 |
E0791 appears in 2 coverage policies from Anthem, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Anthem | External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings (CG-DME-21) | covered if criteria are met | Nov 6, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Nutritional Support (MED201.011) HCPCS Codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, | listed, no stance | Jan 1, 2026 | payer document |
Prior authorization required or conditional in CO, IL, KY, LA, MA, MD, MS, NE, NY, VA, WY.
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.