20975 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 20975

55 of 55 payer prior-auth lists that name 20975 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Cigna, HealthSpring, Humana, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)AZ Blue-administered Medicare Advantage (M2K)AZprior auth requiredSep 1, 2026AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsJan 22, 2007Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsJan 22, 2007Master Precertification List (For Health Care Providers)
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Spine Surgery
Blue Cross and Blue Shield of IllinoisBlue Cross Community Health Plans (BCCHP), Illinois MedicaidILprior auth requiredOct 1, 2026Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of IllinoisBlue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)ILprior auth requiredeviCore-managedJan 1, 2025Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpringMedicare AdvantageAllprior auth requiredJan 1, 20252026 Q4 Prior Authorization List
HumanaHumana Healthy HorizonsVAprior auth requiredJan 1, 2027Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Neighborhood Health PartnershipNeighborhood Health PartnershipFLprior auth requiredSep 1, 2026Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health PlansOxford Health PlansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Health Plans CHP+COprior auth requiredOct 1, 2026Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Health Plans Prime / RAECOprior auth requiredOct 1, 2026Rocky Mountain Health Plans PRIME Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Medicare Advantage D-SNPCOprior auth requiredFeb 1, 2025Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
SurestSurest health plansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcareUnitedHealthcare CommercialAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Individual Exchange plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Mid-Atlantic Health PlansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare West commercial plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare of the River ValleyAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community PlanAHCCCS Complete Care (ACC)AZprior auth requiredOct 1, 2026Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community PlanALTCS Developmentally DisabledAZprior auth requiredOct 1, 2026Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community PlanALTCS Long Term CareAZprior auth requiredOct 1, 2026Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community PlanKanCareKSprior auth requiredOct 1, 2026Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community PlanMassachusetts OneCareMAprior auth requiredNov 1, 2025Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO)MAprior auth requiredNov 1, 2025CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO) and OneCareMAprior auth requiredOct 1, 2026Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community PlanMichigan Medicaid, Healthy Michigan Plan, CSHCSMIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community PlanMinnesota Metro MedicaidMNprior auth requiredOct 1, 2024Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community PlanMississippi CHIPMSprior auth requiredApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth requiredApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community PlanNebraska Heritage HealthNEprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community PlanNew Jersey FamilyCareNJprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community PlanNew Mexico Turquoise CareNMprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth requiredNov 1, 2025Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community PlanPennsylvania CHIPPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth requiredMay 1, 2026Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community PlanTennCareTNprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth requiredJan 1, 2015Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community PlanTexas STARTXprior auth requiredJan 1, 2015Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community PlanTexas STAR KidsTXprior auth requiredNov 1, 2016Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community PlanTexas STAR+PLUSTXprior auth requiredJan 1, 2015Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of Hawaii (QUEST Integration)HIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJan 1, 2015Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community PlanVirginia Cardinal Care LTSSVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community PlanVirginia Cardinal Care MedicaidVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth requiredOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community PlanWisconsin BadgerCare Plus and Medicaid SSIWIprior auth requiredSep 1, 2026Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 20975

20975 appears in 31 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, Capital Blue Cross, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaBone Growth Stimulators (0343)covered if criteria are metMay 26, 2026payer document
AetnaBone and Tendon Graft Substitutes and Adjuncts (0411)listed, no stanceAug 18, 2026payer document
AetnaComplementary and Alternative Medicine (0388)listed, no stanceJun 25, 2026payer document
AetnaRemote Ischemic Conditioning (0814)listed, no stance (range 20000-29999)Nov 20, 2025payer document
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 20100-29999)Jul 29, 2026payer document
Blue Cross & Blue Shield of MississippiElectrical Bone Growth Stimulation Of The Appendicular Skeletonunproven / investigationalpayer document
Blue Cross & Blue Shield of MississippiElectrical Stimulation Of The Spine As An Adjunct To Spinal Fusion Procedurescovered if criteria are metpayer document
Blue Cross Blue Shield of MassachusettsElectrical Bone Growth Stimulation of the Appendicular Skeleton (499)unproven / investigationalpayer document
Blue Cross Blue Shield of MassachusettsElectrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures (498)listed, no stancepayer document
Blue Cross NCElectrical Bone Growth Stimulationlisted, no stanceJun 1, 2026payer document
Blue Shield of CaliforniaElectrical Bone Growth Stimulation of the Appendicular Skeleton (7.01.07)listed, no stancepayer document
Blue Shield of CaliforniaElectrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures (7.01.85)listed, no stancepayer document
Capital Blue CrossElectrical Bone Growth Stimulation of the Appendicular Skeleton (MP 1.024)
Procedure codes
unproven / investigationalSep 1, 2026payer document
CenteneOsteogenic Stimulation (CP.MP.194)covered if criteria are metMay 1, 2026payer document
CignaBone Growth Stimulators: Electrical (Invasive), Ultrasound (0084)covered if criteria are metMay 15, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Electrical Bone Growth Stimulation of the Appendicular Skeleton (SUR705.044)listed, no stanceOct 1, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures (SUR705.013)listed, no stanceOct 15, 2026payer document
Premera Blue CrossElectrical Bone Growth Stimulation of the Appendicular Skeleton (7.01.07)listed, no stanceJun 8, 2026payer document
Premera Blue CrossElectrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures (7.01.85)listed, no stanceJul 13, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (CS037.T)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (2026T0561X)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Idaho Only) (CS037ID.C)
Electrical Bone Growth Stimulator: Non-Spinal (Invasive, Non-Invasive)
listed, no stanceJun 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Kansas Only) (CS037KS.02)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Kentucky Only) (CS037KY.10)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Nebraska Only) (CS037NE.S)
Electrical Bone Growth Stimulator: Non-Spinal (Invasive, Non-Invasive)
listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for New Jersey Only) (CS037NJ.V)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for New Mexico Only) (CS037NM.C)
Electrical Bone Growth Stimulator: Non-Spinal (Invasive, Non-Invasive)
listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for North Carolina Only) (CSNCT0561.06)
Electrical Bone Growth Stimulator: Non-Spinal (Invasive, Non-invasive)
listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Ohio Only) (CS037OH.D)
Electrical Bone Growth Stimulator: Non-Spinal (Invasive, Non-Invasive)
listed, no stanceFeb 1, 2026payer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Pennsylvania Only) (CS037PA.S)listed, no stancepayer document
UnitedHealthcareElectrical and Ultrasonic Bone Growth Stimulators (for Tennessee Only) (CS037TN.S)listed, no stanceFeb 1, 2026payer document

Recent prior-auth changes

  • Jan 1, 2027: PA added, Humana
  • Apr 1, 2026: PA removed, UnitedHealthcare
  • Apr 1, 2026: PA removed, UnitedHealthcare
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2025: conditions changed, Neighborhood Health Partnership
  • Mar 1, 2025: PA added, Rocky Mountain Health Plans
  • Mar 1, 2025: PA added, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in VA, WA.

  • AZ: $182.70 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025
  • CO: $145.74 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $131.18 (physician, non-facility), effective Jan 1, 2026
  • IL: $123.14 (practitioner), effective Apr 1, 2024
  • IN: $133.93 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KY: $0.00 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $0.00 (asc), effective May 1, 2026
  • MS: $138.57 (comprehensive), effective Jul 1, 2026
  • ND: $172.73 (physician), effective Aug 1, 2026
  • NE: $413.00 (asc), effective Jul 1, 2024
  • NY: $87.04 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $144.52 (physician), effective Jan 1, 2000
  • OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
  • TX: $21.25 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026
  • VA: $146.12 (medical), effective Jul 1, 2026
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $98.03 (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.