G0158 Hhc ot assistant ea 15Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
Status E: excluded from the PFS by regulation.
56 of 56 payer prior-auth lists that name G0158 require prior authorization or set conditions: Aetna, Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Blue Shield of California, CarePlus Health Plans, HealthSpring, 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, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California | Blue Shield commercial | CA | prior auth under conditions | CalPERS ASO only | Sep 1, 2026 | Prior Authorization List for Blue Shield |
| Aetna | Commercial | All | prior auth required | Not required for Student Health or Allina Health | Aetna plans | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Medicare Advantage | All | prior auth required | Not required for Student Health or Allina Health | Aetna plans; Delegated by state: Carelon (FL, GA, KY, OH, OK, TX, VA), eviCore (NJ, NY, PA, WV), Tango (NV, from 2026-09-01) | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Oct 1, 2026 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 | |
| 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) |
| HealthSpring | Medicare Advantage | All | prior auth required | Aug 1, 2026 | 2026 Q4 Prior Authorization List | |
| 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 (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 | FL | prior auth required | Jan 1, 2027 | 1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List | |
| Humana | Humana Healthy Horizons | KY | prior auth required | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. | |
| 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 | ||
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth under conditions | PA after 60 day | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 |
| Molina Complete Care (Virginia) | Virginia state exceptions to the national Medicaid grid (exceptions only) | VA | prior auth under conditions | State exception; PA after 5 visits | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth under conditions | State exception; PA after 5 visits | 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 under conditions | PA after 60 day | 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 | 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 under conditions | PA after 60 day | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth under conditions | PA after 60 day | 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 required | PA required after initial 6 visits per rolling year for home health | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | No PA required for the first THREE 30-day episodes within a calendar year | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | 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 Mississippi | Medicaid | MS | prior auth required | 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 required | Prior authorization is required for all home health services | 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 Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | 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 | 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 | 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 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 | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth under conditions | PA after 60 day | 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 Washington | Medicare Advantage | WA | prior auth under conditions | PA after 60 day | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth under conditions | PA after 60 day | 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 under conditions | PA after 60 day | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Check fee schedule for coverage | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| UnitedHealthcare Community Plan | Massachusetts OneCare | MA | prior auth under conditions | site of care: home, outpatient | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) | MA | prior auth under conditions | site of care: home, outpatient | Nov 1, 2025 | CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025 |
| 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 | New Mexico Turquoise Care | NM | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth under conditions | site of care: home, outpatient | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
| 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 |
G0158 appears in 14 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Rhode Island, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Attention Deficit/Hyperactivity Disorder (0426) | not covered | Jul 7, 2026 | payer document |
| Aetna | Occupational Therapy (0250) | listed, no stance | May 19, 2026 | payer document |
| Anthem | Home Health (CG-MED-23) | covered if criteria are met | Nov 6, 2025 | payer document |
| Anthem | Home Hospice (CG-MED-101) | covered if criteria are met | Feb 19, 2026 | payer document |
| Anthem | Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology (CG-REHAB-12) | covered if criteria are met | Aug 13, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | DRAFT Home Health Care Services - Skilled Services | covered if criteria are met | Oct 1, 2026 | payer document |
| UnitedHealthcare | Home Health Care Services (for Kentucky Only) (CS137KY.12) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (CS137.X) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (MP.022.28) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (for Kansas Only) (CS137KS.04) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (for Nebraska Only) (CS137NE.V) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (for New Mexico Only) (CS137NM.D) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (for Ohio Only) (CS137OH.E) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Home Health, Skilled, and Custodial Care Services (for Tennessee Only) (CS137TN1.J) | listed, no stance | Jan 1, 2026 | payer document |
Prior authorization required or conditional in 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.