`22526` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22526

44 of 45 payer prior-auth lists that name 22526 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, CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, 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 Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), 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)
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 22, 2007	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jan 22, 2007	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 MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2020	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)
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	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	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
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 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 22526

22526 appears in 24 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Shield of California, BlueCross BlueShield of South Carolina, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Intradiscal Procedures (0602)	not covered	Sep 2, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	covered if criteria are met (range 22526-22527)	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
Anthem	Percutaneous Vertebral Disc Procedures (SURG.00052)	unproven / investigational	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Percutaneous Intradiscal Electrothermal Annuloplasty Radiofrequency Annuloplasty Biacuplasty And Intraosseous Basivertebral Nerve Ablation	unproven / investigational		payer document
Blue Cross & Blue Shield of Rhode Island	Minimally Invasive Procedures for Back Pain	not covered	Aug 19, 2026	payer document
Blue Shield of California	BSC9.01 \| Investigational Services	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Biacuplasty (CAM 70172)	listed, no stance	Dec 1, 2025	payer document
Cigna	Intraoperative Monitoring (0509)	not covered	Sep 15, 2025	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty (SUR712.023)	listed, no stance	Nov 15, 2025	payer document
Premera Blue Cross	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty,and Intraosseous Basivertebral Nerve Ablation (7.01.72)	listed, no stance	Jun 22, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (2026T0105EE)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (CS031.T)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Idaho Only) (CS031ID.B)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Kansas Only) (CS031KS.02)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Kentucky Only) (CS031KY.06)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Nebraska Only) (CS031NE.T)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for New Jersey Only) (CS031NJ.R)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for New Mexico Only) (CS031NM.C)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Ohio Only) (CS031OH.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Pennsylvania Only) (CS031PA.R)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Discogenic Pain Treatment (for Tennessee Only) (CS031TN.R)	listed, no stance	Feb 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: PA removed, Oxford Health Plans
Jan 1, 2026: PA removed, Humana
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Nov 1, 2025: PA removed, Blue Cross and Blue Shield of Illinois

Medicaid fee-for-service

Prior authorization required or conditional in WA, WY.

CO: $1573.59 (chp_plus, non-facility), effective Jul 1, 2026
IN: $254.52 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $1120.31 (default, Exempt Physician), effective Dec 18, 2009
KY: $257.02 (physician, facility), effective Jan 1, 2026
LA: $1353.57 (professional), effective Feb 1, 2013
MA: $242.68 (physician_surgery, facility), effective May 1, 2024
ND: $2166.59 (physician), effective Aug 1, 2026
NY: $168.74 (physician_surgery, facility), effective Jul 1, 2026
OH: $262.59 (physician, facility), effective Dec 31, 2013
OK: $258.75 (physician, facility), effective Jul 1, 2026
TX: $262.76 (physician, Physician, facility), effective Mar 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $170.27 (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.

22526 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22526

Payer coverage policies that name 22526

Recent prior-auth changes

Medicaid fee-for-service

`22526` CPT® code: payer coverage and prior authorization