11623 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 11623

6 of 6 payer prior-auth lists that name 11623 require prior authorization or set conditions: Neighborhood Health Partnership, Oxford Health Plans, UnitedHealthcare.

PayerPlanStatePrior authConditionsSinceSource
Neighborhood Health PartnershipNeighborhood Health PartnershipFLprior auth under conditionssite of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WISep 1, 2026Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health PlansOxford Health PlansAllprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior Authorization Requirements for Oxford Effective October 1, 2026
UnitedHealthcareUnitedHealthcare CommercialAllprior auth under conditionssite of care: outpatient hospital; not in AK, GU, IL, MA, PR, RI, TX, UT, VI, WIOct 1, 2026Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth under conditionssite of care: outpatient hospitalSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Individual Exchange plansAllprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare of the River ValleyAllprior auth under conditionssite of care: outpatient hospital; not in AK, IL, MA, PR, RI, TX, UT, VI, WIOct 1, 2026Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026

Payer coverage policies that name 11623

11623 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 10040-19499)Jul 29, 2026payer document

Recent prior-auth changes

  • Aug 1, 2026: conditions changed, UnitedHealthcare
  • Jul 1, 2026: conditions changed, UnitedHealthcare
  • Jul 1, 2026: conditions changed, Neighborhood Health Partnership
  • Jul 1, 2026: conditions changed, UnitedHealthcare
  • Jun 1, 2026: conditions changed, UnitedHealthcare
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Jul 1, 2025: conditions changed, UnitedHealthcare
  • Jul 1, 2025: conditions changed, Neighborhood Health Partnership

Medicaid fee-for-service

  • AZ: $99.73 (asc), effective Oct 1, 2026
  • CO: $225.66 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $306.55 (pediatric_surgery, pediatric surgeon), effective Jan 1, 2025
  • IL: $141.23 (practitioner), effective Apr 1, 2024
  • IN: $161.57 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $300.00 (asc, facility), effective Aug 1, 1982
  • KY: $177.92 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $153.99 (asc), effective May 1, 2026
  • MS: $139.22 (comprehensive, facility), effective Oct 1, 2025
  • ND: $175.99 (physician, facility), effective Aug 1, 2026
  • NE: $220.55 (physician, facility), effective Jul 1, 2026
  • NY: $92.91 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $120.36 (physician, facility), effective Jan 1, 2024
  • OK: $162.32 (asc), effective Jan 1, 2026
  • TX: $146.46 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $153.94 (medical, facility), effective Jul 1, 2026
  • VT: $1282.40 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $105.30 (physician, facility), effective Jul 1, 2026
  • WY: $730.40 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.