64484 CPT® code: payer coverage and prior authorization73 of 74 payer prior-auth lists that name 64484 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, HealthSpring, Humana, Medicare, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Gold-card eligible (lumbar spine only) | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | AZ | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | NJ | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | OH | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | OK | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | TX | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Medicare | WISeR Model (Wasteful and Inappropriate Service Reduction) | WA | prior auth required | Jan 15, 2026 | WISeR Model Provider and Supplier Operational Guide, Version 7.0 | |
| Aetna | Medicare Advantage | All | prior auth required | Not required for Student Health or Allina Health | Aetna plans | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Commercial | All | prior auth required | Not required for Student Health or Allina Health | Aetna plans | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2016 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2016 | Master Precertification List (For Health Care Providers) |
| Cigna | Musculoskeletal | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| Cigna | Musculoskeletal | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Interventional Pain Management |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | eviCore-managed | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth under conditions | site of care: outpatient | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List |
| Humana | Humana D-SNP (FL) | FL | prior auth under conditions | site of care: outpatient | 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 under conditions | site of care: outpatient | Jan 1, 2027 | Humana Dual Fully Integrated Illinois Prior Authorization and Notification List |
| Humana | Humana D-SNP (IN) | IN | prior auth under conditions | site of care: outpatient | 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 under conditions | site of care: outpatient | Jan 1, 2027 | 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List |
| Humana | Humana D-SNP (SC) | SC | prior auth under conditions | site of care: outpatient | Jan 1, 2027 | Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List |
| Humana | Humana D-SNP (VA) | VA | prior auth under conditions | site of care: outpatient | Jan 1, 2027 | Virginia Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | IL | prior auth under conditions | site of care: outpatient | 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 under conditions | site of care: outpatient | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. |
| Humana | Humana Healthy Horizons | OK | prior auth required | Jan 1, 2027 | Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list | |
| Humana | Humana Healthy Horizons | SC | prior auth under conditions | site of care: outpatient | 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 under conditions | site of care: outpatient | 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 under conditions | site of care: outpatient | 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 | Musculoskeletal | All | prior auth under conditions | site of care: outpatient | Humana Prior Authorization List (PAL): Musculoskeletal Services | |
| Humana | Musculoskeletal | All | prior auth under conditions | site of care: outpatient | Humana Prior Authorization List (PAL): Musculoskeletal Services | |
| Humana | Musculoskeletal | All | prior auth under conditions | site of care: outpatient | Humana Prior Authorization List (PAL): Musculoskeletal Services | |
| Humana | Oak Street Health | All | prior auth under conditions | site of care: outpatient | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Authorization required in any setting | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth required | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 | |
| Oxford Health Plans | Oxford Health Plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 | |
| Surest | Surest health plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 |
64484 appears in 30 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Cigna, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Back Pain - Invasive Procedures (0016) | covered if criteria are met | Oct 6, 2026 | payer document |
| Aetna | Back Pain - Invasive Procedures (0016) | listed, no stance (range 64479-64484) | Oct 6, 2026 | payer document |
| Aetna | Complex Regional Pain Syndrome (CRPS): Treatments (0447) | covered if criteria are met (range 64479-64484) | Jul 16, 2026 | payer document |
| Aetna | Headaches: Nonsurgical Management (0462) | not covered | Jul 23, 2026 | payer document |
| Aetna | Infusion Pumps (0161) | covered if criteria are met (range 64400-64530) | Mar 31, 2026 | payer document |
| Aetna | Intraoperative Neurophysiological Monitoring (0697) | not covered (range 64479-64484) | Jun 19, 2026 | payer document |
| Aetna | Intravenous Iron Therapy (0575) | listed, no stance (range 61000-64999) | Jul 1, 2026 | payer document |
| Aetna | Nerve Blocks (0863) | not covered | Jul 23, 2026 | payer document |
| Aetna | Post-Herpetic Neuralgia (0725) | covered if criteria are met | Oct 20, 2025 | payer document |
| Aetna | Respiratory Devices: Incentive Spirometers, Vaporizers and Intermittent Positive Pressure Breathing Machines (0479) | listed, no stance (range 61000-64999) | Jul 9, 2026 | payer document |
| Aetna | Spinal Ultrasound (0628) | listed, no stance (range 64400-64530) | Sep 11, 2026 | payer document |
| Aetna | Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow (0703) | listed, no stance (range 61000-64999) | Nov 24, 2025 | payer document |
| Aetna | Transforaminal Epidural Injections (0722) | covered if criteria are met | Oct 20, 2025 | payer document |
| Aetna | Ultrasound Guidance – Selected Indications (0952) | not covered | Apr 27, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Epidural Steroid Injections (L.2.01.416) | covered if criteria are met | payer document | |
| BlueCross BlueShield of South Carolina | Epidural Spinal Injections (CAM 136) | listed, no stance | Sep 1, 2026 | payer document |
| Capital Blue Cross | Epidural Steroid Injections for Back Pain (MP 4.014) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
| Capital Blue Cross | Neural Therapy (MP 8.012) Procedure codes | unproven / investigational | Feb 1, 2026 | payer document |
| Centene | Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) | covered if criteria are met | Jul 1, 2026 | payer document |
| Cigna | Anesthesia Services for Interventional Pain Management Procedures in an Adult (0551) | covered if criteria are met | Sep 15, 2026 | payer document |
| Cigna | Intraoperative Monitoring (0509) | not covered | Sep 15, 2025 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (CS039.AB) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (2026T0616O) | listed, no stance | Sep 10, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for Kansas Only) (CS039KS.03) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for Nebraska Only) (CS039NE.AB) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for New Jersey Only) (CS039NJ.U) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for New Mexico Only) (CS039NM.D) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for North Carolina Only) (CSNCT0004.08) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for Ohio Only) (CS039OH.D) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for Pennsylvania Only) (CS039PA.Z) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Epidural Steroid Injections for Spinal Pain (for Tennessee Only) (CS039TN.Z) | listed, no stance | Jul 1, 2026 | payer document |
Prior authorization required or conditional in WA.
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.