`92633` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 92633

28 of 30 payer prior-auth lists that name 92633 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required	Carelon-managed	Aug 1, 2025	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2020	Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Humana	Humana Healthy Horizons	FL	prior auth required		Jan 1, 2027	1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2023	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth under conditions	PA after 12 visits per calendar year	Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth under conditions	PA after 12 visits per calendar year	Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required	State exception; PA required after initial evaluation for PT/OT/ST. No PA required for initial evaluation	Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of New Mexico	Medicaid	NM	prior auth under conditions	PA after 12 visits per calendar year	Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required	Participating Providers: Initial evaluation does not require prior authorization	Jul 1, 2023	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth under conditions	State exception; PA after 20 visits per calendar year	Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	Age 21+; Prior authorization required for members ages 21 and older	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Jul 1, 2017	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required		Jul 1, 2017	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth required		Jul 1, 2017	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Jul 1, 2017	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Jul 1, 2017	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U

Payer coverage policies that name 92633

92633 appears in 5 coverage policies from Aetna, Blue Cross NC.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Aural Rehabilitation (0034)	covered if criteria are met	Mar 10, 2026	payer document
Aetna	Bone-Anchored Hearing Aids (0403)	listed, no stance (range 92630-92633)	Jul 22, 2026	payer document
Aetna	Cochlear Implants and Auditory Brainstem Implants (0013)	covered if criteria are met (range 92630-92633)	Aug 18, 2026	payer document
Aetna	Speech Therapy (0243)	covered if criteria are met	May 13, 2026	payer document
Blue Cross NC	Cochlear Implant	listed, no stance	Aug 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2026: conditions changed, Passport by Molina Healthcare (Kentucky)
Jan 1, 2026: conditions changed, Molina Healthcare of Michigan
Jan 1, 2026: PA removed, Humana
Jan 1, 2026: PA added, Blue Cross and Blue Shield of Illinois
Nov 1, 2025: PA removed, Blue Cross and Blue Shield of Illinois
Jul 1, 2025: conditions changed, Passport by Molina Healthcare (Kentucky)
Apr 1, 2025: conditions changed, Molina Complete Care (Virginia)
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Jan 1, 2025: PA added, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in LA, MS.

AZ: $42.81 (physician, AHCCCS PT 08, facility), effective Oct 1, 2020
CO: $42.80 (health_first_colorado), effective Jul 1, 2026
FL: $69.35 (hearing, non-facility), effective Apr 6, 2026
IN: $89.73 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $0.00 (physician, facility), effective Jan 1, 2026
ND: $0.00 (physician), effective Aug 1, 2026
OK: $52.78 (physician, non-facility), effective Jul 1, 2026
TX: $62.01 (audiologist, Audiologist, non-facility), effective Mar 1, 2026
VA: $95.91 (medical), effective Jan 1, 2006
VT: $0.00 (outpatient_hospital_opps), effective Feb 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.

92633 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 92633

Payer coverage policies that name 92633

Recent prior-auth changes

Medicaid fee-for-service

`92633` CPT® code: payer coverage and prior authorization