Payer policies › CPT 0122001220 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 01220 Payer coverage policies that name 01220 01220 appears in 2 coverage policies from Aetna, Anthem.
Payer Policy Role in policy Reviewed Document Aetna Manipulation Under General Anesthesia (0204) listed, no stance Mar 25, 2026 payer document Anthem Anesthesia Services and Moderate (“Conscious”) Sedation (CG-MED-21) covered if criteria are met (range 01200-01274) Nov 6, 2025 payer document
Medicaid fee-for-service AZ: $32.12 (anesthesia), effective Oct 1, 2026 CO: $16.98 (chp_plus, non-facility), effective Jul 1, 2026 FL: $65.85 (physician, non-facility), effective Jan 1, 2026 IN: $0.00 (professional, facility), effective Oct 16, 2003 KS: $0.00 (default, Exempt Physician), effective Jan 1, 2026 KY: $45.00 (asc), effective Jan 1, 2026 MA: $4.00 (anesthesia), effective Aug 1, 2021 MS: $4.00 (anesthesia), effective Oct 1, 2003 NY: $4.00 (physician_anesthesia), effective Apr 1, 2026 OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $4.00 (certified_registered_nurse_anesthetist_crna_anesthesiologist, Certified Registered Nurse Anesthetist (Crna) / Anesthesiologist Assistant (Aa), facility), effective Mar 1, 2019 VA: $3.00 (medical), effective Oct 1, 1987 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $4.00 (physician, facility), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), 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.