`A4220` Infusion pump refill kit

Refill kit for implantable infusion pump

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 1 units per day (clinical), rationale: Clinical: Data

Medicare pricing for A4220

Physician Fee Schedule (CY 2026, RVU26D)

Status P: bundled or excluded, no separate PFS payment.

Payer policies and prior authorization for A4220

1 of 1 payer prior-auth lists that name A4220 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Mar 1, 2023	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)

Payer coverage policies that name A4220

A4220 appears in 3 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Infusion Pumps (0161)	covered if criteria are met	Mar 31, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Implantable Infusion Pump (L.7.01.430)	covered if criteria are met		payer document
BlueCross BlueShield of South Carolina	Implantable Infusion Pump for Pain and Spasticity (CAM 70141)	listed, no stance	Jan 1, 2026	payer document

Medicaid fee-for-service

Prior authorization required or conditional in IL, MA.

CO: $73.62 (health_first_colorado), effective Jul 1, 2026
IN: $146.43 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
ND: $72.05 (dme), effective Aug 1, 2026
NE: $73.63 (dme), effective Jul 1, 2026
OK: $17.31 (dme), effective Aug 1, 2020
TX: $43.62 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Apr 1, 2019
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $24.61 (home_infusion_parenteral_nutrition), 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.

A4220 Infusion pump refill kit