22222 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22222

52 of 53 payer prior-auth lists that name 22222 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Humana, 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 Mississippi, 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, and others.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)Federal Employee Program (FEP)AZprior auth under conditionsFEP Blue Focus onlySep 1, 2026Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
AetnaCommercialAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
AetnaMedicare AdvantageAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
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)
HumanaHumana Healthy HorizonsKYprior auth requiredJan 1, 2027please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
HumanaHumana Healthy HorizonsSCprior auth requiredJan 1, 2027Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Molina Complete Care (Virginia)Medicare-only PA matrix for D-SNPVAprior auth requiredJan 1, 2022Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)MedicaidVAprior auth requiredApr 1, 2025Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of ArizonaMedicare-only PA matrix for D-SNPAZprior auth requiredJan 1, 2022Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of CaliforniaMedicare AdvantageCAprior auth requiredJul 1, 2021Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of FloridaMedicare AdvantageFLprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of IdahoMedicare AdvantageIDprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of IdahoMedicaidIDprior auth requiredJan 1, 2025Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of IowaMedicaidIAprior auth requiredJul 1, 2023IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of MichiganMedicare AdvantageMIprior auth requiredJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of MichiganMedicaidMIprior auth requiredJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of MichiganExchangeMIprior auth requiredJul 1, 2021Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of MississippiMedicaidMSprior auth requiredJan 1, 2025Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of NevadaMedicaidNVprior auth requiredOct 1, 2022Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New MexicoMedicaidNMprior auth requiredJul 1, 2026New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of New MexicoMedicare AdvantageNMprior auth requiredJan 1, 2021Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioMedicare and MyCare Ohio (MMP) MedicareOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South CarolinaMedicare AdvantageSCprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of TexasSTARTXprior auth requiredFeb 19, 2025Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of TexasSTAR+PLUSTXprior auth requiredFeb 19, 2025Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of TexasSTAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)TXprior auth requiredJul 1, 2026Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of TexasExchangeTXprior auth requiredSep 1, 2019Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of UtahMedicaidUTprior auth requiredJan 1, 2025Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of UtahMedicare AdvantageUTprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of WashingtonMedicare AdvantageWAprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of WisconsinMedicare AdvantageWIprior auth requiredOct 1, 2021Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)Molina national (MHI) Medicare gridAllprior auth requiredOct 1, 2021Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)MedicaidKYprior auth requiredJul 1, 2026Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
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
SurestSurest health plansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcarePreferred Care Network and Preferred Care Partners of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida 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 Medicare Advantage, Peoples Health and Dual Complete (D-SNP)Allprior auth requiredExcluded plans: Erickson AdvantageOct 1, 2026UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements 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 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 PlanUnitedHealthcare Community Plan of KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 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

Payer coverage policies that name 22222

22222 appears in 19 coverage policies from Aetna, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaBack Pain - Invasive Procedures (0016)listed, no stance (range 22220-22226)Oct 6, 2026payer document
AetnaIntraoperative Neurophysiological Monitoring (0697)covered if criteria are met (range 22206-22226)Jun 19, 2026payer document
AetnaIntraoperative Neurophysiological Monitoring (0697)not covered (range 22010-22899)Jun 19, 2026payer document
AetnaNerve Blocks (0863)listed, no stance (range 22010-22899)Jul 23, 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
AetnaSpinal Surgery: Laminectomy and Fusion (0743)covered if criteria are metJul 30, 2026payer document
AetnaSpinal Surgery: Laminectomy and Fusion (0743)listed, no stanceJul 30, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (2026T0639J)listed, no stanceSep 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (CS365.E)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Idaho Only) (CS365ID.D)listed, no stanceJun 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Kansas Only) (CS365KS.02)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Kentucky Only) (CS365KY.05)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for New Jersey Only) (CS365NJ.E)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for New Mexico Only) (CS365NM.C)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for North Carolina Only) (CSNCT0365.05)listed, no stanceJun 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Ohio Only) (CS365OH.D)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Pennsylvania Only) (CS365PA.E)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpinal Fusion and Decompression (for Tennessee Only) (CS365TN.E)listed, no stanceMay 1, 2026payer document
UnitedHealthcareSpine Procedures (MMP089.18)
Thoracic Spine Surgery		listed, no stanceAug 1, 2026payer document
UnitedHealthcareThis Medical Policy only applies to the State of Nebraska. (CS365NE.E)listed, no stanceMay 1, 2026payer document

Recent prior-auth changes

  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan

Medicaid fee-for-service

  • AZ: $3026.13 (asc), effective Oct 1, 2026
  • CO: $1328.54 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $1249.40 (physician, non-facility), effective Jan 1, 2026
  • IL: $1274.73 (practitioner), effective Apr 1, 2024
  • IN: $1306.93 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $781.54 (asc, facility), effective Jul 1, 1987
  • KY: $994.71 (physician, facility), effective Jan 1, 2026
  • LA: $289.27 (professional), effective Jul 1, 2025
  • MA: $1308.00 (physician_surgery), effective May 1, 2024
  • MS: $1434.56 (comprehensive), effective Jul 1, 2026
  • ND: $2126.56 (physician, facility), effective Aug 1, 2026
  • NE: $1607.96 (physician, non-facility), effective Jul 1, 2026
  • NY: $694.02 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $970.21 (physician), effective Jan 1, 2024
  • OK: $1524.35 (physician, non-facility), effective Jul 1, 2026
  • TX: $223.51 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026
  • VA: $1537.04 (medical), effective Jul 1, 2026
  • VT: $5634.17 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $1027.16 (physician, facility), effective Jul 1, 2026
  • WY: $3208.96 (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.