A4604 Tubing with heating elementTubing with integrated heating element for use with positive airway pressure device
Status X: statutory exclusion, not paid under the PFS.
12 of 12 payer prior-auth lists that name A4604 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Michigan, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington.
| 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 | Oct 1, 2026 | 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, 2025 | 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) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Contact eviCore for PA | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Jul 1, 2021 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | vendor review only eviCore in IL/MI/OH/NY/WI | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
A4604 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, BlueCross BlueShield of South Carolina.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Obstructive Sleep Apnea in Adults (0004) | covered if criteria are met | Oct 6, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Multifunction Home Ventilators Medicare Advantage Plans and Commercial Products | listed, no stance | May 15, 2024 | payer document |
| BlueCross BlueShield of South Carolina | Diagnosis of Obstructive Sleep Apnea Syndrome (CAM 20118) | listed, no stance | Aug 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Medical Management of Obstructive Sleep Apnea Syndrome (CAM 80167) | listed, no stance | Aug 1, 2026 | payer document |
Prior authorization required or conditional in CO, MA, VA, WV.
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.