`4220F` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 4220F

Payer coverage policies that name 4220F

4220F appears in 4 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082)	listed, no stance (range 42200-42225)	Mar 18, 2026	payer document
Aetna	Distraction Osteogenesis for Craniofacial Defects (0549)	listed, no stance (range 42200-42225)	Jul 30, 2026	payer document
Aetna	Orthognathic Surgery (0095)	covered if criteria are met (range 42200-42281)	Mar 18, 2026	payer document
Aetna	Stereolithographic Models and Implants (0613)	listed, no stance (range 42200-42225)	Sep 3, 2026	payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

VT: $0.00 (outpatient_hospital_opps), effective Feb 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.

4220F CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 4220F

Payer coverage policies that name 4220F

Medicaid fee-for-service

`4220F` CPT® code: payer coverage and prior authorization