43226 CPT® code: payer coverage and prior authorization2 of 2 payer prior-auth lists that name 43226 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth required | site of care: site of service reviewed | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth under conditions | site of care: outpatient hospital | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 |
43226 appears in 4 coverage policies from Aetna, Centene, Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Dysphagia Therapy (0625) | covered if criteria are met | Sep 25, 2025 | payer document |
| Aetna | Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) | covered if criteria are met (range 43200-43232) | Oct 29, 2025 | payer document |
| Aetna | Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) | listed, no stance | Oct 29, 2025 | payer document |
| Centene | Anesthesiology Services for Gastrointestinal Endoscopy (CP.MP.161) | covered if criteria are met | May 1, 2019 | payer document |
| Regence | Surgical Site of Care – Hospital Outpatient (Utilization Management 19) | listed, no stance | May 1, 2026 | payer document |
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.