54522 CPT® code: payer coverage and prior authorization2 of 2 payer prior-auth lists that name 54522 require prior authorization or set conditions: Humana, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
54522 appears in 2 coverage policies from Aetna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (0929) | listed, no stance | Jul 17, 2026 | payer document |
| Aetna | Radium Ra 223 Dichloride (Xofigo) (0874) | listed, no stance | Dec 22, 2025 | 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.