`22853` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22853

44 of 44 payer prior-auth lists that name 22853 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, Humana, Neighborhood Health Partnership, Oxford 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)	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)
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)
Blue Cross Blue Shield of Arizona (AZ Blue)	Teamsters group (TYW)	AZ	prior auth required	Gold-card eligible	Sep 1, 2026	Teamsters Group 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	Aug 23, 2019	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Aug 23, 2019	Master Precertification List (For Health Care Providers)
Cigna	Musculoskeletal	All	prior auth under conditions	Add-on code: requested with the primary procedure	Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Spine Surgery
Cigna	Musculoskeletal	All	prior auth under conditions	Add-on code: requested with the primary procedure	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)
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
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
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest 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 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	North Carolina Medicaid	NC	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
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

Payer coverage policies that name 22853

22853 appears in 41 coverage policies from Aetna, BlueCross BlueShield of South Carolina, 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	Bone and Tendon Graft Substitutes and Adjuncts (0411)	listed, no stance	Aug 18, 2026	payer document
Aetna	Idiopathic Scoliosis (0398)	covered if criteria are met	Sep 28, 2026	payer document
Aetna	Intraoperative Neurophysiological Monitoring (0697)	covered if criteria are met (range 22840-22870)	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	Orthopedic Casts, Braces and Splints (0009)	listed, no stance (range 22840-22855)	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
BlueCross BlueShield of South Carolina	Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) (CAM 701107)	listed, no stance	Jun 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Interspinous Fixation (Fusion) Devices (SUR712.040)	listed, no stance	Nov 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
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Medical Policies Moving to MCG Guidelines Fusion \| 22552, 22554, 22590, 22595, \| S-320	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Interspinous Fixation (Fusion) Devices (7.01.591)	listed, no stance	Jun 8, 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	Cervical Spinal Fusion (Surgery 244)	listed, no stance	Mar 1, 2026	payer document
Regence	Lumbar Spinal Fusion (Surgery 187)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (CS363.D)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (2026T0638H)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Idaho Only) (CS363ID.C)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Kansas Only) (CS363KS.02)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Kentucky Only) (CS363KY.04)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Nebraska Only) (CS363NE.D)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for New Jersey Only) (CS363NJ.D)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for New Mexico Only) (CS363NM.C)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for North Carolina Only) (CSNCT0363.04)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Ohio Only) (CS363OH.D)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Pennsylvania Only) (CS363PA.D)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Interspinous Fusion and Decompression Devices (for Tennessee Only) (CS363TN.D)	listed, no stance	Jan 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	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 WA.

AZ: $261.15 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025
CO: $200.35 (chp_plus, non-facility), effective Jul 1, 2026
FL: $177.94 (physician, non-facility), effective Jan 1, 2026
IL: $178.97 (practitioner), effective Apr 1, 2024
IN: $189.23 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $132.73 (default, Exempt Physician), effective Aug 1, 2024
KY: $0.00 (asc), effective Jan 1, 2026
LA: $248.24 (professional), effective Jan 1, 2017
MA: $0.00 (asc), effective May 1, 2026
MS: $189.71 (comprehensive), effective Jul 1, 2026
ND: $227.55 (physician), effective Aug 1, 2026
NE: $231.19 (physician, non-facility), effective Jul 1, 2026
NY: $151.95 (physician_surgery, facility), effective Jul 1, 2026
OH: $214.53 (physician), effective Jan 1, 2017
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $199.86 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026
VA: $198.21 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $129.95 (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.

22853 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 22853

Payer coverage policies that name 22853

Recent prior-auth changes

Medicaid fee-for-service

`22853` CPT® code: payer coverage and prior authorization