40652 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 40652

2 of 2 payer prior-auth lists that name 40652 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)Federal Employee Program (FEP)AZprior auth requiredSep 1, 2026Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth under conditionsonly with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890Sep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026

Medicaid fee-for-service

Prior authorization required or conditional in ND.

  • AZ: $163.89 (asc), effective Oct 1, 2026
  • CO: $292.28 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $281.59 (physician, facility), effective Jan 1, 2026
  • IL: $351.89 (practitioner), effective Apr 1, 2024
  • IN: $281.38 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $250.00 (asc, facility), effective Aug 1, 1982
  • KY: $288.42 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $189.71 (asc), effective May 1, 2026
  • MS: $218.43 (comprehensive, facility), effective Oct 1, 2025
  • ND: $170.02 (physician, facility), effective Aug 1, 2026
  • NE: $413.00 (asc), effective Jul 1, 2024
  • NY: $170.74 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $263.97 (physician, facility), effective Jan 1, 2024
  • OK: $263.13 (asc), effective Jan 1, 2026
  • TX: $187.22 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $313.66 (medical, facility), effective Jul 1, 2026
  • VT: $418.77 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $238.51 (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.