Payer policies › CPT 2210322103 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 22103 23 of 23 payer prior-auth lists that name 22103 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana, Neighborhood Health Partnership, UnitedHealthcare, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source Blue Cross Blue Shield of Arizona (AZ Blue) Federal Employee Program (FEP) AZ prior auth under conditions FEP Blue Focus only Sep 1, 2026 Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) Aetna Commercial All prior auth required Oct 1, 2026 Participating provider precertification list for Aetna® Aetna Medicare Advantage All prior auth required Oct 1, 2026 Participating provider precertification list for Aetna® CarePlus Health Plans CarePlus Health Plans FL prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana D-SNP (FL) FL prior auth required Jan 1, 2027 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois Prior Authorization and Notification List Humana Humana D-SNP (IN) IN prior auth required Jan 1, 2027 *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List Humana Humana D-SNP (MI) MI prior auth required Jan 1, 2027 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List Humana Humana D-SNP (SC) SC prior auth required Jan 1, 2027 Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List Humana Humana D-SNP (VA) VA prior auth required Jan 1, 2027 Virginia Prior Authorization and Notification List Humana Humana Healthy Horizons IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . Humana Humana Healthy Horizons IN prior auth required Jan 1, 2027 1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a Humana Humana Healthy Horizons KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. Humana Humana MA and D-SNP All prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana Puerto Rico MA and Dual Medicare-Medicaid PR prior auth required Nov 3, 2025 Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification Humana Musculoskeletal All prior auth required Humana Prior Authorization List (PAL): Musculoskeletal Services Humana Musculoskeletal All prior auth required Humana Prior Authorization List (PAL): Musculoskeletal Services Humana Musculoskeletal All prior auth required Humana Prior Authorization List (PAL): Musculoskeletal Services Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth required Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth required Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 UnitedHealthcare Community Plan UnitedHealthcare Community Plan of Kentucky KY prior auth required Jul 1, 2026 Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 UnitedHealthcare Community Plan UnitedHealthcare Connected (Texas MMP) TX prior auth required Jan 1, 2015 Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
Payer coverage policies that name 22103 22103 appears in 4 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Intraoperative Neurophysiological Monitoring (0697) covered if criteria are met (range 22100-22116) Jun 19, 2026 payer document Aetna Intraoperative Neurophysiological Monitoring (0697) not covered (range 22010-22899) Jun 19, 2026 payer document Aetna Nerve Blocks (0863) listed, no stance (range 22010-22899) Jul 23, 2026 payer document Aetna Remote Ischemic Conditioning (0814) listed, no stance (range 20000-29999) Nov 20, 2025 payer document Aetna Skin and Soft Tissue Substitutes (0244) not covered (range 20100-29999) Jul 29, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, Surest Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Apr 1, 2026: PA removed, UnitedHealthcare Community Plan Medicaid fee-for-service AZ: $3624.41 (outpatient_hospital), effective Oct 1, 2013 CO: $105.31 (chp_plus, non-facility), effective Jul 1, 2026 FL: $91.68 (physician, non-facility), effective Jan 1, 2026 IL: $92.22 (practitioner), effective Apr 1, 2024 IN: $99.43 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $52.70 (default, Exempt Physician), effective Aug 1, 2024 KY: $0.00 (asc), effective Jan 1, 2026 LA: $112.90 (professional), effective Feb 1, 2013 MA: $0.00 (asc), effective May 1, 2026 MS: $97.51 (comprehensive), effective Jul 1, 2026 ND: $119.03 (physician), effective Aug 1, 2026 NE: $251.94 (physician, non-facility), effective Jul 1, 2026 NY: $70.25 (physician_surgery, facility), effective Jul 1, 2026 OH: $121.60 (physician), effective Jan 1, 2000 OK: $102.72 (physician, non-facility), effective Jul 1, 2026 TX: $16.49 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026 VA: $100.41 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $66.69 (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.