Payer policies › CPT 6487464874 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 64874 Payer coverage policies that name 64874 64874 appears in 4 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Gender Affirming Surgery (0615) covered if criteria are met Sep 8, 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 Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow (0703) listed, no stance (range 61000-64999) Nov 24, 2025 payer document
Medicaid fee-for-service AZ: $2392.99 (outpatient_hospital), effective Oct 1, 2013 CO: $134.85 (chp_plus, non-facility), effective Jul 1, 2026 FL: $118.58 (physician, non-facility), effective Jan 1, 2026 IL: $171.15 (practitioner), effective Apr 1, 2024 IN: $129.87 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $850.00 (asc, facility), effective Aug 1, 1982 KY: $0.00 (asc), effective Jan 1, 2026 LA: $217.00 (asc), effective Jul 1, 2012 MA: $0.00 (asc), effective May 1, 2026 MS: $125.10 (comprehensive), effective Jul 1, 2026 ND: $153.58 (physician), effective Aug 1, 2026 NE: $637.00 (asc), effective Jul 1, 2024 NY: $87.84 (physician_surgery, facility), effective Jul 1, 2026 OH: $140.32 (physician), effective Jan 1, 2002 OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $21.20 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2025 VA: $128.76 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $85.61 (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.