G6017 Intrafraction track motionIntra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg,3d positional tracking, gating, 3d surface tracking), each fraction of treatment
27 of 29 payer prior-auth lists that name G6017 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, 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, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Rocky Mountain Health Plans, UnitedHealthcare Community Plan.
| 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) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | 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 required | 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 Florida | Medicare Advantage | FL | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), 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 Idaho | Medicare Advantage | ID | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Contact eviCore for PA | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | cancer dx via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | cancer dx via NCH | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 |
| 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 New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| 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 | Exchange | TX | prior auth required | Jul 1, 2020 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | 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 required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| 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 | |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth required | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 | |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth required | Apr 1, 2025 | Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025 | |
| 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 |
G6017 appears in 1 coverage policy from Blue Cross & Blue Shield of Mississippi.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Blue Cross & Blue Shield of Mississippi | Realtime Intrafraction Motion Management During Radiation Therapy (L.2.03.401) | unproven / investigational | payer document |
Prior authorization required or conditional in IN.
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.