`64494` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 64494

66 of 67 payer prior-auth lists that name 64494 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		Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Medicare	Prior Authorization for Certain Hospital OPD Services	All	prior auth required		Jul 1, 2023	Prior Authorization (PA) Program for Certain Hospital OPD Services Operational Guide, Appendix A
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 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	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	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 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	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Oak Street Health	All	prior auth required			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	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
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 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	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
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	Medicare Advantage	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	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
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 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
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name 64494

64494 appears in 28 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	Blood and Adipose Tissue Derived Products for Selected Indications (0784)	listed, no stance	Nov 19, 2025	payer document
Aetna	Complex Regional Pain Syndrome (CRPS): Treatments (0447)	listed, no stance (range 64490-64505)	Jul 16, 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 64490-64495)	Jun 19, 2026	payer document
Aetna	Intravenous Iron Therapy (0575)	listed, no stance (range 61000-64999)	Jul 1, 2026	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	Ultrasound Guidance – Selected Indications (0952)	not covered	Apr 27, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Facet Blocks For Treatment Of Back Pain (L.7.01.407)	covered if criteria are met		payer document
BlueCross BlueShield of South Carolina	Paravertebral Facet Joint Injections/Blocks (CAM 137)	listed, no stance	Jul 1, 2026	payer document
Capital Blue Cross	Facet Joint Denervation (MP 5.049) Procedure codes	unproven / investigational	Apr 1, 2026	payer document
Capital Blue Cross	Facet Joint Injections and Medial Branch Blocks (MP 4.050) Procedure codes	covered if criteria are met	May 1, 2026	payer document
Centene	Facet Joint Interventions (CP.MP.171)	covered if criteria are met	May 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	Facet Joint and Medial Branch Block Injections for Spinal Pain (2026T0004WW)	listed, no stance	Sep 10, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (CS178.J)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Idaho Only) (CS178ID.D)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Kansas Only) (CS178KS.02)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Nebraska Only) (CS178NE.K)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for New Jersey Only) (CS178NJ.F)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for New Mexico Only) (CS178NM.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for North Carolina Only) (CSNCT0005.07)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Ohio Only) (CS178OH.D)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Pennsylvania Only) (CS178PA.H)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Facet Joint and Medial Branch Block Injections for Spinal Pain (for Tennessee Only) (CS178TN.H)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Feb 1, 2026: PA added, Humana
Jan 1, 2026: conditions changed, Humana
Jan 1, 2026: PA added, Humana
Nov 1, 2024: PA added, UnitedHealthcare
Jul 1, 2024: PA removed, Molina Healthcare of Illinois

Medicaid fee-for-service

Prior authorization required or conditional in WA.

AZ: $40.80 (outpatient_hospital, RF133), effective Oct 1, 2025
CO: $55.53 (chp_plus, non-facility), effective Jul 1, 2026
FL: $34.93 (physician, facility), effective Jan 1, 2026
IL: $34.66 (practitioner), effective Apr 1, 2024
IN: $39.47 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $66.55 (asc, facility), effective Jan 1, 2010
KY: $0.00 (asc), effective Jan 1, 2026
LA: $71.71 (professional), effective Jul 1, 2025
MA: $0.00 (asc), effective May 1, 2026
MS: $37.71 (comprehensive), effective Jul 1, 2026
ND: $105.89 (physician), effective Aug 1, 2026
NE: $413.00 (asc), effective Jul 1, 2024
NY: $21.38 (physician_surgery, facility), effective Jul 1, 2026
OH: $25.96 (physician, facility), effective Jan 1, 2024
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $37.13 (certified_registered_nurse_anesthetist_crna_anesthesiologist, Certified Registered Nurse Anesthetist (Crna) / Anesthesiologist Assistant (Aa), facility), effective Mar 1, 2025
VA: $37.91 (medical, facility), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $25.61 (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.

64494 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 64494

Payer coverage policies that name 64494

Recent prior-auth changes

Medicaid fee-for-service

`64494` CPT® code: payer coverage and prior authorization