Payer policies › CPT 5581255812 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 55812 10 of 10 payer prior-auth lists that name 55812 require prior authorization or set conditions: CarePlus Health Plans, Humana.
Payer Plan State Prior auth Conditions Since Source 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 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 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
Payer coverage policies that name 55812 55812 appears in 1 coverage policy from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Ablative Procedures for Prostate Cancer (0843) listed, no stance Feb 25, 2026 payer document
Medicaid fee-for-service AZ: $1642.93 (physician, AHCCCS PT 08, facility), effective Oct 1, 2025 CO: $1303.95 (chp_plus, non-facility), effective Jul 1, 2026 FL: $1112.60 (physician, non-facility), effective Jan 1, 2026 IL: $1567.08 (practitioner), effective May 20, 2025 IN: $1237.78 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $620.57 (default, Exempt Physician), effective Aug 1, 2024 KY: $1274.01 (physician, facility), effective Jan 1, 2026 LA: $1378.27 (professional), effective Feb 1, 2013 MA: $1172.04 (physician_surgery), effective May 1, 2024 MS: $1216.32 (comprehensive), effective Jul 1, 2026 ND: $1524.50 (physician), effective Aug 1, 2026 NE: $2111.84 (physician, non-facility), effective Jul 1, 2026 NY: $809.58 (physician_surgery, facility), effective Jul 1, 2026 OH: $1180.06 (physician), effective Jan 1, 2000 OK: $1280.03 (physician, non-facility), effective Jul 1, 2026 TX: $188.90 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026 VA: $1239.29 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $835.68 (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.