`22630` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22630

113 of 113 payer prior-auth lists that name 22630 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, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, 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, and others.

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)	Federal Employee Program (FEP)	AZ	prior auth required		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®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Oct 1, 2006	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		Jan 1, 2025	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 Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
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)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
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 Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
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 California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
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 Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
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	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
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	Medicare and MyCare Ohio (MMP) Medicare	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 South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
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
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
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
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required		Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 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
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans 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 Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth required	Excluded plans: Erickson Advantage	Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 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 West commercial plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare West commercial 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

Payer coverage policies that name 22630

22630 appears in 40 coverage policies from Aetna, Blue Cross NC, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Back Pain - Invasive Procedures (0016)	covered if criteria are met	Oct 6, 2026	payer document
Aetna	Back Pain - Invasive Procedures (0016)	listed, no stance (range 22548-22812)	Oct 6, 2026	payer document
Aetna	Bone and Tendon Graft Substitutes and Adjuncts (0411)	listed, no stance (range 22590-22634)	Aug 18, 2026	payer document
Aetna	Bone and Tendon Graft Substitutes and Adjuncts (0411)	listed, no stance (range 22548-22819)	Aug 18, 2026	payer document
Aetna	Idiopathic Scoliosis (0398)	covered if criteria are met (range 22548-22819)	Sep 28, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	covered if criteria are met (range 22532-22819)	Jun 19, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	covered if criteria are met	Jun 19, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	not covered (range 22010-22899)	Jun 19, 2026	payer document
Aetna	Negative Pressure Wound Therapy (0334)	listed, no stance (range 22532-22819)	Jun 8, 2026	payer document
Aetna	Nerve Blocks (0863)	listed, no stance	Jul 23, 2026	payer document
Aetna	Nerve Blocks (0863)	listed, no stance (range 22010-22899)	Jul 23, 2026	payer document
Aetna	Orthopedic Casts, Braces and Splints (0009)	listed, no stance (range 22548-22812)	Jan 20, 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)	covered if criteria are met	Jul 30, 2026	payer document
Aetna	Spinal Surgery: Laminectomy and Fusion (0743)	listed, no stance	Jul 30, 2026	payer document
Blue Cross NC	Orthopedic Applications of Stem Cell Therapy	listed, no stance	Feb 1, 2026	payer document
Cigna	Intraoperative Monitoring (0509)	not covered	Sep 15, 2025	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Lumbar Spinal Fusion (SUR712.036) CPT Codes 20930, 20931, 20936, 20937, 20938, 20939, 22533, 22534, 22558,	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Lumbar Spinal Fusion in Adults (7.01.542) Page \| 9 of 39 \| ∞	listed, no stance	Jun 1, 2026	payer document
Regence	Lumbar Spinal Fusion (Surgery 187)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (CS364.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (2026T0640H)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Idaho Only) (CS364ID.B)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Kansas Only) (CS364KS.02)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Kentucky Only) (CS364KY.04)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Nebraska Only) (CS364NE.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for New Jersey Only) (CS364NJ.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for New Mexico Only) (CS364NM.C)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for North Carolina Only) (CSNCT0364.04)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Ohio Only) (CS364OH.D)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Pennsylvania Only) (CS364PA.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Minimally Invasive Spine Surgery Procedures (for Tennessee Only) (CS364TN.D)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (CS365.E)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (2026T0639J)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Idaho Only) (CS365ID.D)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Kansas Only) (CS365KS.02)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Kentucky Only) (CS365KY.05)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for New Jersey Only) (CS365NJ.E)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for New Mexico Only) (CS365NM.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for North Carolina Only) (CSNCT0365.05)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Ohio Only) (CS365OH.D)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Pennsylvania Only) (CS365PA.E)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spinal Fusion and Decompression (for Tennessee Only) (CS365TN.E)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Spine Procedures (MMP089.18) Lumbar Spine Surgery	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	This Medical Policy only applies to the State of Nebraska. (CS365NE.E)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana

Medicaid fee-for-service

Prior authorization required or conditional in CO, WA, WY.

AZ: $19114.30 (asc), effective Oct 1, 2026
CO: $1230.98 (chp_plus, non-facility), effective Jul 1, 2026
FL: $1174.94 (physician, non-facility), effective Jan 1, 2026
IL: $1198.70 (practitioner), effective Jul 1, 2026
IN: $1163.26 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $959.08 (default, Exempt Physician), effective Aug 1, 2024
KY: $1158.89 (physician, facility), effective Jan 1, 2026
LA: $255.66 (professional), effective Jul 1, 2025
MA: $1153.85 (physician_surgery), effective May 1, 2024
MS: $1231.54 (comprehensive), effective Jul 1, 2026
ND: $12002.87 (physician, facility), effective Aug 1, 2026
NE: $1896.96 (physician, non-facility), effective Jul 1, 2026
NY: $736.40 (physician_surgery, facility), effective Jul 1, 2026
OH: $1120.74 (physician), effective Jan 1, 2024
OK: $1306.64 (physician, non-facility), effective Jul 1, 2026
TX: $187.85 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026
VA: $1308.74 (medical), effective Jul 1, 2026
VT: $21068.51 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $872.18 (physician, facility), effective Jul 1, 2026
WY: $11999.66 (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.

22630 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22630

Payer coverage policies that name 22630

Recent prior-auth changes

Medicaid fee-for-service

`22630` CPT® code: payer coverage and prior authorization