0622T CPT® code: payer coverage and prior authorization22 of 23 payer prior-auth lists that name 0622T require prior authorization or set conditions: HealthSpring, 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 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), Oxford Health Plans, Rocky Mountain Health Plans, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| HealthSpring | Medicare Advantage | All | prior auth required | Aug 1, 2026 | 2026 Q4 Prior Authorization List | |
| 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 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 | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | 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 | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| 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 | 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 | Exchange | TX | prior auth required | Jul 1, 2021 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | 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 | |
| Oxford Health Plans | Oxford Health Plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 | |
| 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 | UnitedHealthcare West commercial plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
0622T appears in 16 coverage policies from Aetna, Anthem, Blue Cross NC, Blue Shield of California, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Glaucoma Surgery (0484) | not covered | Jul 14, 2026 | payer document |
| Anthem | Laser Trabeculoplasty and Laser Peripheral Iridotomy (CG-SURG-100) | covered if criteria are met | Aug 13, 2026 | payer document |
| Blue Cross NC | Aqueous Shunts and Devices for Glaucoma | listed, no stance | Jun 1, 2026 | payer document |
| Blue Shield of California | | Aqueous Shunts and Stents for Glaucoma (9.03.21) | listed, no stance | payer document | |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Category III Current Procedural Terminology (CPT®) Codes CPT Codes 0054T, 0055T, 0071T, 0072T, 0075T, 0076T, 0095T, 0098T, 0100T, 0101T, | listed, no stance | Jan 1, 2027 | payer document |
| Premera Blue Cross | Non-covered Experimental/Investigational Services Page | 4 of 38 | ∞ | listed, no stance | Oct 1, 2026 | payer document |
| Regence | Surgical Treatments for Glaucoma (Surgery 227) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (2026T0443MM) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (CS050.Y) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Kansas Only) (CS050KS.03) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Kentucky Only) (CS050KY.09) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Nebraska Only) (CS050NE.Y) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for New Mexico Only) (CS050NM.E) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Ohio Only) (CS050OH.D) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Pennsylvania Only) (CS050PA.V) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Tennessee Only) (CS050TN.V) | listed, no stance | Feb 1, 2026 | 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.