Payer policies › CPT 2653626536 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 26536 14 of 14 payer prior-auth lists that name 26536 require prior authorization or set conditions: CarePlus Health Plans, Humana.
Payer Plan State Prior auth Conditions Since Source 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 KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. 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
Payer coverage policies that name 26536 26536 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.
Payer Policy Role in policy Reviewed Document Aetna Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (0798) covered if criteria are met Feb 24, 2026 payer document Aetna Metatarsal Phalangeal Joint Replacement (0708) listed, no stance Nov 24, 2025 payer document Aetna Nerve Blocks (0863) listed, no stance (range 26010-26989) 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) listed, no stance (range 26535-26536) Jul 29, 2026 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 Pyrocarbon Metacarpophalangeal And Proximal Interphalangeal Joint Implants (L.7.01.411) unproven / investigational payer document
Recent prior-auth changes Jun 1, 2026: PA removed, UnitedHealthcare Jun 1, 2026: PA removed, UnitedHealthcare Jun 1, 2026: PA removed, UnitedHealthcare Community Plan Apr 1, 2026: PA removed, UnitedHealthcare Community Plan Medicaid fee-for-service Prior authorization required or conditional in WV.
AZ: $3620.90 (asc), effective Oct 1, 2026 CO: $620.93 (chp_plus, non-facility), effective Jul 1, 2026 FL: $568.64 (physician, non-facility), effective Jan 1, 2026 IL: $524.40 (practitioner), effective Jul 1, 2026 IN: $574.62 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $300.00 (asc, facility), effective Aug 1, 1982 KY: $4668.49 (asc), effective Jan 1, 2026 LA: $265.13 (asc), effective Jul 1, 2012 MA: $3162.77 (asc), effective May 1, 2026 MS: $3694.87 (comprehensive, facility), effective Oct 1, 2025 ND: $2752.08 (physician, facility), effective Aug 1, 2026 NE: $1000.00 (asc), effective Jul 1, 2024 NY: $324.49 (physician_surgery, facility), effective Jul 1, 2026 OH: $435.51 (physician), effective Jan 1, 2024 OK: $4259.16 (asc), effective Jan 1, 2026 TX: $3290.94 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $633.39 (medical), effective Jul 1, 2026 VT: $5634.17 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $415.35 (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.