Payer policies › CPT 4312243122 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 43122 1 of 1 payer prior-auth lists that name 43122 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois.
Payer Plan State Prior auth Conditions Since Source 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
Payer coverage policies that name 43122 43122 appears in 5 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Barrett's Esophagus (0728) covered if criteria are met Nov 25, 2025 payer document Aetna Botulinum Toxin (0113) not covered (range 43107-43124) Jul 14, 2026 payer document Aetna Dostarlimab-gxly (Jemperli) (0993) listed, no stance Jan 27, 2026 payer document Aetna Indocyanine Green Angiography (0111) listed, no stance (range 43116-43123) Mar 18, 2026 payer document Aetna Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (0892) listed, no stance Jul 16, 2026 payer document
Recent prior-auth changes Jul 1, 2026: PA removed, HealthSpring Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois Medicaid fee-for-service AZ: $2607.70 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $1982.74 (chp_plus, non-facility), effective Jul 1, 2026 FL: $1817.10 (physician, non-facility), effective Jan 1, 2026 IL: $1803.97 (practitioner), effective Apr 1, 2024 IN: $1913.23 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $1521.82 (default, Exempt Physician), effective Aug 1, 2024 KY: $1487.25 (physician, facility), effective Jan 1, 2026 LA: $417.02 (professional), effective Jul 1, 2025 MA: $1849.53 (physician_surgery), effective May 1, 2024 MS: $1950.84 (comprehensive), effective Jul 1, 2026 ND: $2384.00 (physician), effective Aug 1, 2026 NE: $3445.64 (physician, non-facility), effective Jul 1, 2026 NY: $1199.65 (physician_surgery, facility), effective Jul 1, 2026 OH: $1447.15 (physician), effective Jan 1, 2024 OK: $2058.23 (physician, non-facility), effective Jul 1, 2026 TX: $275.24 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026 VA: $2024.02 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $1342.10 (physician, facility), effective Jul 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.