12047 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 12047

Payer coverage policies that name 12047

12047 appears in 3 coverage policies from Aetna, Anthem.

PayerPolicyRole in policyReviewedDocument
AetnaBone and Tendon Graft Substitutes and Adjuncts (0411)listed, no stance (range 12031-12057)Aug 18, 2026payer document
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 10040-19499)Jul 29, 2026payer document
AnthemTreatment of Keloids and Scar Revision (CG-SURG-31)covered if criteria are met (range 12031-13153)May 14, 2026payer document

Medicaid fee-for-service

  • AZ: $662.63 (asc), effective Oct 1, 2026
  • CO: $145.92 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $268.86 (physician, facility), effective Jan 1, 2026
  • IL: $270.45 (practitioner), effective Jun 24, 2019
  • IN: $266.21 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $176.28 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $1101.65 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $696.96 (asc), effective May 1, 2026
  • MS: $784.87 (comprehensive, facility), effective Oct 1, 2025
  • ND: $649.43 (physician, facility), effective Aug 1, 2026
  • NE: $413.00 (asc), effective Jul 1, 2024
  • NY: $161.60 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $181.86 (physician, facility), effective Jan 1, 2024
  • OK: $1005.06 (asc), effective Jan 1, 2026
  • TX: $709.01 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $299.48 (medical, facility), effective Jul 1, 2026
  • VT: $1602.06 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $912.46 (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.