`22513` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22513

76 of 76 payer prior-auth lists that name 22513 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, HealthSpring, Humana, Medicare, Neighborhood Health Partnership, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	AZ	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	NJ	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	OH	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	OK	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	TX	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Medicare	WISeR Model (Wasteful and Inappropriate Service Reduction)	WA	prior auth required		Jan 15, 2026	WISeR Model Provider and Supplier Operational Guide, Version 7.0
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2015	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2015	Master Precertification List (For Health Care Providers)
Cigna	Musculoskeletal	All	prior auth required		Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Spine Surgery
Cigna	Musculoskeletal	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required	Carelon-managed	Aug 1, 2025	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2025	Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Aug 1, 2026	2026 Q4 Prior Authorization List
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 Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana 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
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	site of care: site of service reviewed	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 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	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior 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 Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior 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 Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior 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 Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required	site of care: site of service reviewed	Apr 1, 2022	Prior 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 Plan	Texas STAR	TX	prior auth required	site of care: site of service reviewed	Apr 1, 2022	Prior 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 Plan	Texas STAR Kids	TX	prior auth required	site of care: site of service reviewed	Apr 1, 2022	Prior 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 Plan	Texas STAR+PLUS	TX	prior auth required	site of care: site of service reviewed	Apr 1, 2022	Prior 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 Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 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 Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Apr 1, 2022	Prior 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 Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth required		Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth required		Sep 1, 2026	Prior 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 22513

22513 appears in 23 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Back Pain - Invasive Procedures (0016)	covered if criteria are met (range 22513-22514)	Oct 6, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	covered if criteria are met (range 22510-22515)	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
Aetna	Spinal Surgery: Laminectomy and Fusion (0743)	listed, no stance	Jul 30, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Minimally Invasive Approaches To Vertebral Fractures And Osteolytic Lesions Of The Spine	covered if criteria are met		payer document
Blue Cross NC	Orthopedic Applications of Stem Cell Therapy	listed, no stance	Feb 1, 2026	payer document
Blue Shield of California	Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine (6.01.25)	listed, no stance		payer document
Premera Blue Cross	Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine (6.01.25)	listed, no stance	Jun 8, 2026	payer document
Regence	Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty (Surgery 107)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (2026T0581Q)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (CS330.F)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Idaho Only) (CS330ID.C)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Kansas Only) (CS330KS.02)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Kentucky Only) (CS330KY.10)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Nebraska Only) (CS330NE.F)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for New Jersey Only) (CS330NJ.F)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for New Mexico Only) (CS330NM.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for North Carolina Only) (CSNCT0581.04)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Ohio Only) (CS330OH.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Pennsylvania Only) (CS330PA.E)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Percutaneous Vertebroplasty and Kyphoplasty (for Tennessee Only) (CS330TN.F)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, Oxford Health Plans
Oct 1, 2026: conditions changed, UnitedHealthcare
Aug 1, 2026: PA added, HealthSpring
Mar 1, 2026: conditions changed, UnitedHealthcare
Feb 1, 2026: conditions changed, UnitedHealthcare
Mar 1, 2025: PA added, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in WV.

AZ: $3026.13 (asc), effective Oct 1, 2026
CO: $1306.73 (chp_plus, non-facility), effective Jul 1, 2026
FL: $352.77 (physician, facility), effective Jan 1, 2026
IL: $352.92 (practitioner), effective Apr 1, 2024
IN: $386.15 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $2252.66 (asc, facility), effective Jan 1, 2015
KY: $3607.39 (asc), effective Jan 1, 2026
LA: $6005.03 (professional), effective Jan 1, 2015
MA: $2382.86 (asc), effective May 1, 2026
MS: $2808.67 (comprehensive, facility), effective Oct 1, 2025
ND: $2126.56 (physician, facility), effective Aug 1, 2026
NE: $948.48 (physician, non-facility), effective Jul 1, 2026
NY: $275.71 (physician_surgery, facility), effective Jul 1, 2026
OH: $403.43 (physician, facility), effective Jan 1, 2015
OK: $3291.10 (asc), effective Jan 1, 2026
TX: $2398.52 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $392.94 (medical, facility), effective Jul 1, 2026
VT: $5634.17 (outpatient_hospital_opps), effective Feb 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.

22513 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22513

Payer coverage policies that name 22513

Recent prior-auth changes

Medicaid fee-for-service

`22513` CPT® code: payer coverage and prior authorization