Payer policies › CPT 6712167121 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 67121 2 of 2 payer prior-auth lists that name 67121 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth under conditions site of care: outpatient hospital Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
Payer coverage policies that name 67121 67121 appears in 1 coverage policy from Regence.
Payer Policy Role in policy Reviewed Document Regence Surgical Site of Care – Hospital Outpatient (Utilization Management 19) listed, no stance May 1, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Medicaid fee-for-service AZ: $932.80 (asc), effective Oct 1, 2026 CO: $718.69 (chp_plus, non-facility), effective Jul 1, 2026 FL: $614.69 (physician, non-facility), effective Jan 1, 2026 IL: $595.36 (practitioner), effective Apr 1, 2024 IN: $692.97 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $400.00 (asc, facility), effective Aug 1, 1982 KY: $1225.78 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $860.81 (asc), effective May 1, 2026 MS: $971.45 (comprehensive, facility), effective Oct 1, 2025 MT: $864.19 (optometric, facility), effective Jul 1, 2025 ND: $722.60 (physician, facility), effective Aug 1, 2026 NE: $1000.00 (asc), effective Jul 1, 2024 NY: $386.86 (physician_surgery, facility), effective Jul 1, 2026 OH: $571.55 (physician), effective Jan 1, 2024 OK: $1118.31 (asc), effective Jan 1, 2026 TX: $849.94 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $662.33 (medical), effective Jul 1, 2026 VT: $1791.94 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $339.40 (asc), effective Jul 1, 2026 WY: $1020.61 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.