75822 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 75822

6 of 12 payer prior-auth lists that name 75822 require prior authorization or set conditions: Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Ohio.

PayerPlanStatePrior authConditionsSinceSource
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of IllinoisMedicaidILprior auth requiredJan 1, 2022Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of MichiganMedicare AdvantageMIprior auth requiredadults via EvolentJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of MichiganMedicaidMIprior auth under conditionsadults via Evolent; no PA for pediatricsJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth under conditionsvia NCH; PA for age over 18Oct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth under conditionsvia NCH; PA for age over 18Oct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01

Payer coverage policies that name 75822

75822 appears in 2 coverage policies from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaAcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis (0414)listed, no stanceJul 9, 2026payer document
AetnaVaricose Veins (0050)listed, no stanceAug 3, 2026payer document

Recent prior-auth changes

  • Jan 1, 2026: PA added, Molina Healthcare of Michigan
  • Jul 1, 2024: conditions changed, Molina Healthcare of Illinois
  • Jan 1, 2024: PA added, Molina Healthcare of Michigan

Medicaid fee-for-service

  • AZ: $36.18 (asc), effective Oct 1, 2026
  • CO: $110.28 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $48.65 (radiology), effective Jan 1, 2026
  • IL: $88.11 (practitioner), effective Apr 1, 2024
  • IN: $102.38 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $46.25 (asc, facility), effective Jan 1, 2020
  • KY: $64.55 (asc), effective Jan 1, 2026
  • LA: $42.04 (lab_radiology), effective Jul 1, 2025
  • MA: $49.89 (physician_radiology), effective May 1, 2024
  • MS: $49.94 (comprehensive, facility), effective Oct 1, 2025
  • ND: $63.85 (physician, facility), effective Aug 1, 2026
  • NE: $157.13 (physician, non-facility), effective Jul 1, 2026
  • NY: $64.64 (ordered_ambulatory), effective Jul 24, 2026
  • OH: $84.38 (physician), effective Jan 1, 2024
  • OK: $58.89 (asc), effective Jan 1, 2026
  • TX: $1922.67 (hospital_outpatient_imaging_services, Rural Hospitals), effective Mar 1, 2025
  • VA: $57.00 (medical), effective Jul 1, 2026
  • VT: $1222.27 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $81.03 (physician, facility), effective Jul 1, 2026
  • WY: $696.15 (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.