64643 CPT® code: payer coverage and prior authorization1 of 1 payer prior-auth lists that name 64643 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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) |
64643 appears in 17 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Botulinum Toxin (0113) | covered if criteria are met (range 64642-64645) | Jul 14, 2026 | payer document |
| Aetna | Intraoperative Neurophysiological Monitoring (0697) | not covered (range 64600-64647) | Jun 19, 2026 | payer document |
| Aetna | Intravenous Iron Therapy (0575) | listed, no stance (range 61000-64999) | Jul 1, 2026 | payer document |
| Aetna | Plantar Fasciitis Treatments (0235) | not covered (range 64642-64645) | Apr 27, 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 | Spasticity Management (0362) | not covered (range 64642-64645) | May 26, 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 | Botulinum Toxin (L.5.01.491) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Botulinum Toxin (S.5.01.491) | not covered | payer document | |
| BlueCross BlueShield of South Carolina | Botulinum Toxin (CAM 50105) | listed, no stance | Nov 1, 2025 | payer document |
| Cigna | Botulinum Toxin – Dysport (IP0638) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Botulinum Toxin – Xeomin (IP0639) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Botulinum Toxins – Botox (IP0637) | covered if criteria are met | May 15, 2026 | payer document |
| Cigna | Botulinum Toxins – Myobloc (IP0509) | covered if criteria are met | Nov 15, 2025 | payer document |
| Cigna | Botulinum Toxins – Myobloc (IP0509) | listed, no stance | Nov 15, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Botulinum Toxin (RX501.019) CPT Codes 31513, 31570, 31571, 43192, 43201, 43236, 46505, 52287, 64611, | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Botulinum Toxin (5.01.512) | listed, no stance | Sep 8, 2026 | payer document |
Prior authorization required or conditional in WA, WV.
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.