Payer policies › CPT 4363143631 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 43631 18 of 18 payer prior-auth lists that name 43631 require prior authorization or set conditions: Aetna, CarePlus Health Plans, Cigna, Humana.
Payer Plan State Prior auth Conditions Since Source Aetna Commercial All prior auth required Oct 1, 2026 Participating provider precertification list for Aetna® Aetna Medicare Advantage All prior auth required Oct 1, 2026 Participating provider precertification list for Aetna® Cigna ACA/IFP All prior auth required Oct 1, 2006 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required Oct 1, 2006 Master Precertification List (For Health Care Providers) 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 FL prior auth required Jan 1, 2027 1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List Humana Humana Healthy Horizons IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . Humana Humana Healthy Horizons KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. Humana Humana Healthy Horizons SC prior auth required Jan 1, 2027 Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical 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 Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Payer coverage policies that name 43631 43631 appears in 9 coverage policies from Aetna, Cigna, Regence.
Payer Policy Role in policy Reviewed Document Aetna Barrett's Esophagus (0728) not covered Nov 25, 2025 payer document Aetna Gastroesophageal Reflux Disease (GERD) (0213) not covered Jul 21, 2026 payer document Aetna Headaches: Invasive Procedures (0707) not covered (range 43631-43635) Jul 23, 2026 payer document Aetna Infertility (0327) not covered (range 43631-43635) Jul 16, 2026 payer document Aetna Obesity Surgery (0157)Sleeve gastrectomy with SIPS, Laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication not covered Jul 21, 2026 payer document Aetna Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines (0479) listed, no stance (range 43631-43635) Jul 9, 2026 payer document Cigna Bariatric Surgery and Procedures (0051) not covered Jul 15, 2026 payer document Regence Bariatric Surgery (Surgery 58) listed, no stance Dec 1, 2025 payer document Regence Gastroesophageal Reflux Surgery (Surgery 186)NOTES listed, no stance Feb 1, 2026 payer document
Medicaid fee-for-service AZ: $1483.94 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $1135.62 (chp_plus, non-facility), effective Jul 1, 2026 FL: $1054.41 (physician, non-facility), effective Jan 1, 2026 IL: $1023.49 (practitioner), effective Apr 1, 2024 IN: $1089.56 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $542.77 (default, Exempt Physician), effective Aug 1, 2024 KY: $928.88 (physician, facility), effective Jan 1, 2026 LA: $236.70 (professional), effective Jul 1, 2025 MA: $1059.96 (physician_surgery), effective May 1, 2024 MS: $1127.69 (comprehensive), effective Jul 1, 2026 ND: $1387.07 (physician), effective Aug 1, 2026 NE: $355.10 (physician, non-facility), effective Jul 1, 2026 NY: $659.22 (physician_surgery, facility), effective Jul 1, 2026 OH: $914.74 (physician), effective Jan 1, 2024 OK: $1191.26 (physician, non-facility), effective Jul 1, 2026 TX: $167.70 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026 VA: $1174.48 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $781.60 (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.