69637 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 69637

Payer coverage policies that name 69637

69637 appears in 4 coverage policies from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaBlood and Adipose Tissue Derived Products for Selected Indications (0784)listed, no stanceNov 19, 2025payer document
AetnaGrid Monitoring and Intraoperative Electroencephalography (0289)listed, no stance (range 69635-69646)Apr 17, 2026payer document
AetnaMyringotomy and Tympanostomy Tube (0418)listed, no stance (range 69420-69799)Jun 30, 2026payer document
AetnaTinnitus Treatments (0406)listed, no stance (range 69631-69646)Jul 10, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in WV.

  • AZ: $1943.46 (asc), effective Oct 1, 2026
  • CO: $1150.52 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $999.08 (physician, non-facility), effective Jan 1, 2026
  • IL: $937.23 (practitioner), effective Apr 1, 2024
  • IN: $1073.67 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $450.00 (asc, facility), effective Aug 1, 1982
  • KY: $2953.46 (asc), effective Jan 1, 2026
  • LA: $265.13 (asc), effective Jul 1, 2012
  • MA: $1909.57 (asc), effective May 1, 2026
  • MS: $2333.88 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1741.07 (physician, facility), effective Aug 1, 2026
  • NE: $1233.00 (asc), effective Jul 1, 2024
  • NY: $686.80 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $894.16 (physician), effective Jan 1, 2024
  • OK: $2694.50 (asc), effective Jan 1, 2026
  • TX: $1954.22 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $1112.85 (medical), effective Jul 1, 2026
  • VT: $4596.52 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $366.60 (asc), effective Jul 1, 2026
  • WY: $2617.97 (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.