A4225 Sup/ext insulin inf pump syrSupplies for external insulin infusion pump, syringe type cartridge, sterile, each
Status X: statutory exclusion, not paid under the PFS.
1 of 1 payer prior-auth lists that name A4225 require prior authorization or set conditions: Humana.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Humana | Humana Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification |
A4225 appears in 3 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross.
| 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 | External Infusion Pumps (L.1.01.407) | covered if criteria are met | payer document | |
| Capital Blue Cross | External Infusion Pumps for Insulin Delivery and Automated Insulin Delivery Systems (MP 6.007) Procedure codes | covered if criteria are met | May 1, 2026 | payer document |
Prior authorization required or conditional in LA, MA, OH, VA.
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.