Q0491 Emr pwr source combo vad repEmergency power source for use with electric/pneumatic ventricular assist device, replacement only
Status E: excluded from the PFS by regulation.
3 of 3 payer prior-auth lists that name Q0491 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, 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) |
| UnitedHealthcare Community Plan | Indiana Hoosier Care Connect | IN | prior auth under conditions | Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Indiana PathWays for Aging (MLTSS) | IN | prior auth under conditions | Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026 |
Q0491 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, BlueCross BlueShield of South Carolina, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Ventricular Assist Devices (0654) | covered if criteria are met | Sep 10, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Total Artificial Hearts And Implantable Ventricular Assist Devices | covered if criteria are met | payer document | |
| Blue Shield of California | Total Artificial Hearts and Implantable Ventricular Assist Devices (7.03.11) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Total Artificial Hearts and Implantable Ventricular Assist Devices (CAM 70311) 33991 | ; both arterial and venous access, with transseptal puncture | listed, no stance (range Q0478-Q0509) | Mar 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Ventricular Assist Devices and Total Artificial Hearts (SUR707.017) HCPCS Codes L8698, Q0477, Q0478, Q0479, Q0480, Q0481, Q0482, Q0483, Q0484, Q0485, | listed, no stance | Jan 1, 2026 | payer document |
| Regence | Ventricular Assist Devices and Total Artificial Hearts (Surgery 52) | listed, no stance (range Q0477-Q0509) | Jan 1, 2026 | payer document |
Prior authorization required or conditional in IL, IN, OH, WA.
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.