22864 CPT® code: payer coverage and prior authorization40 of 40 payer prior-auth lists that name 22864 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, HealthSpring, 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, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 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 | 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 | |
| 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 | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| 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 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 | Medicare Advantage | 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 | Medicaid | 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 | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| 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 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 | |
| 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 | |
| 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 | 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 New York | NY | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
22864 appears in 11 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, BlueCross BlueShield of South Carolina, Cigna, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Intervertebral Disc Prostheses (0591) | covered if criteria are met | Sep 18, 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 | 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 |
| Blue Cross & Blue Shield of Mississippi | Artificial Intervertebral Disc Cervical Spine (A.7.01.108) | listed, no stance | payer document | |
| Blue Cross NC | Orthopedic Applications of Stem Cell Therapy | listed, no stance | Feb 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Cervical Spine Procedures (CAM 142) 22862 | Total disc arthroplasty (artificial disc), anterior approach | listed, no stance | Jun 1, 2026 | payer document |
| Cigna | Intraoperative Monitoring (0509) | not covered | Sep 15, 2025 | payer document |
| Regence | Artificial Intervertebral Disc (Surgery 127) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Total Artificial Disc Replacement for the Cervical Spine (for North Carolina Only) (CSNCT0437.08) | listed, no stance | Mar 1, 2026 | payer document |
Prior authorization required or conditional in CO, IN, WA.
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.