Payer policies › CPT 5483054830 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 54830 3 of 3 payer prior-auth lists that name 54830 require prior authorization or set conditions: Humana, Neighborhood Health Partnership, UnitedHealthcare.
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 Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI 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
Payer coverage policies that name 54830 54830 appears in 2 coverage policies from Aetna, Regence.
Payer Policy Role in policy Reviewed Document Aetna Infertility (0327) covered if criteria are met Jul 16, 2026 payer document Regence Surgical Site of Care – Hospital Outpatient (Utilization Management 19) listed, no stance May 1, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Medicaid fee-for-service AZ: $1171.31 (asc), effective Oct 1, 2026 CO: $296.35 (chp_plus, non-facility), effective Jul 1, 2026 FL: $270.42 (physician, non-facility), effective Jan 1, 2026 IL: $299.70 (practitioner), effective Jul 1, 2026 IN: $290.57 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $435.00 (asc, facility), effective Aug 1, 1982 KY: $1681.93 (asc), effective Jan 1, 2026 LA: $217.00 (asc), effective Jul 1, 2012 MA: $671.25 (asc), effective May 1, 2026 MS: $1324.25 (comprehensive, facility), effective Oct 1, 2025 ND: $991.50 (physician, facility), effective Aug 1, 2026 NE: $552.00 (asc), effective Jul 1, 2024 NY: $186.23 (physician_surgery, facility), effective Jul 1, 2026 OH: $250.01 (physician), effective Jan 1, 2024 OK: $1534.46 (asc), effective Jan 1, 2026 TX: $1142.90 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $301.22 (medical), effective Jul 1, 2026 VT: $2737.01 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $339.40 (asc), effective Jul 1, 2026 WY: $1558.88 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.