23155 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 23155

5 of 5 payer prior-auth lists that name 23155 require prior authorization or set conditions: Cigna, HealthSpring.

PayerPlanStatePrior authConditionsSinceSource
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsJan 1, 2016Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsJan 1, 2016Master Precertification List (For Health Care Providers)
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Joint Surgery
HealthSpringMedicare AdvantageAllprior auth requiredJan 1, 20252026 Q4 Prior Authorization List

Payer coverage policies that name 23155

23155 appears in 8 coverage policies from Aetna, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaContinuous Passive Motion (CPM) Machines (0010)listed, no stance (range 23000-23921)Mar 5, 2026payer document
AetnaInfusion Pumps (0161)listed, no stance (range 23000-23921)Mar 31, 2026payer document
AetnaIntraoperative Neurophysiological Monitoring (0697)not covered (range 23000-23929)Jun 19, 2026payer document
AetnaNerve Blocks (0863)listed, no stance (range 23000-23929)Jul 23, 2026payer document
AetnaRemote Ischemic Conditioning (0814)listed, no stance (range 20000-29999)Nov 20, 2025payer document
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 20100-29999)Jul 29, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (for Ohio Only) (CSOH2026D0034.K)
National Drug		listed, no stanceMay 1, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (for Pennsylvania Only) (CSPA2026D0034AS)
National Drug		listed, no stanceMay 1, 2026payer document

Medicaid fee-for-service

  • AZ: $3026.13 (asc), effective Oct 1, 2026
  • CO: $643.66 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $582.15 (physician, non-facility), effective Jan 1, 2026
  • IL: $552.80 (practitioner), effective Apr 1, 2024
  • IN: $617.07 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $502.46 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $3607.39 (asc), effective Jan 1, 2026
  • LA: $233.58 (asc), effective Jul 1, 2012
  • 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: $785.00 (asc), effective Jul 1, 2024
  • NY: $379.70 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $559.40 (physician), effective Jan 1, 2024
  • 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: $648.44 (medical), effective Jul 1, 2026
  • VT: $5634.17 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $366.60 (asc), effective Jul 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.