Payer policies › CPT 6490164901 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 64901 Payer coverage policies that name 64901 64901 appears in 5 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Brachial Plexus Surgery (0850) covered if criteria are met (range 64901-64902) Dec 18, 2025 payer document Aetna Intraoperative Neurophysiological Monitoring (0697) covered if criteria are met (range 64890-64913) 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 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: $74.84 (chp_plus, non-facility), effective Jul 1, 2026 FL: $406.73 (physician, non-facility), effective Jan 1, 2026 IL: $410.75 (practitioner), effective Apr 1, 2024 IN: $445.34 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $262.09 (default, Exempt Physician), effective Aug 1, 2024 KY: $0.00 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $0.00 (asc), effective May 1, 2026 MS: $428.25 (comprehensive), effective Jul 1, 2026 ND: $524.94 (physician), effective Aug 1, 2026 NE: $552.00 (asc), effective Jul 1, 2024 NY: $293.22 (physician_surgery, facility), effective Jul 1, 2026 OH: $522.34 (physician), effective Jan 1, 2000 OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $69.17 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2025 VA: $440.97 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $293.15 (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.