HCPCS Level II › T codes T1004 Nsg aide service up to 15minServices of a qualified nursing aide, up to 15 minutes
Medicare coverage: Not payable by Medicare Status: active (October 2026 file) Medicare pricing for T1004 Physician Fee Schedule (CY 2026, RVU26D) Status I: not valid for Medicare (Medicare uses another code).
Payer policies and prior authorization for T1004 16 of 16 payer prior-auth lists that name T1004 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Humana, Molina Healthcare of Iowa, 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 Jul 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 Jul 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) Humana Humana D-SNP (FL) FL prior auth required Jan 1, 2027 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois Prior Authorization and Notification List Humana Humana D-SNP (SC) SC prior auth required Jan 1, 2027 Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List Humana Humana Healthy Horizons FL prior auth required Jan 1, 2027 1102002FL1026 FLHN8CBEN Humana Healthy Horizons in Florida Preauthorization and Notification List Humana Humana Healthy Horizons IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . Humana Humana Healthy Horizons KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. Humana Humana Healthy Horizons OK prior auth required Jan 1, 2027 Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list Humana Humana LTSS (Dual/integrated plan) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated (HMO D-SNP) Illinois long-term services and supports prior authorization and notification list Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management Molina Healthcare of Iowa Medicaid IA prior auth required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 UnitedHealthcare Community Plan District of Columbia LTSS DC prior auth required Oct 1, 2026 Prior Authorization Requirements for District of Columbia LTSS Effective October 1, 2026 UnitedHealthcare Community Plan KanCare KS prior auth under conditions site of care: home, outpatient Oct 1, 2026 Prior authorization requirements for Kansas Medicaid 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
Payer coverage policies that name T1004 T1004 appears in 15 coverage policies from Aetna, Anthem, Premera Blue Cross, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Home Health Aides (0218) covered if criteria are met Sep 10, 2026 payer document Aetna Skilled Home Health Care Nursing Services (0201) listed, no stance Apr 22, 2026 payer document Aetna Skilled Home Private Duty Nursing Care (0136) listed, no stance Apr 7, 2026 payer document Aetna Wound Care: Home or Outpatient Setting (1054) listed, no stance Dec 23, 2025 payer document Anthem Home Health (CG-MED-23) covered if criteria are met Nov 6, 2025 payer document Premera Blue Cross Non-covered Services and ProceduresPage | 20 of 30 | ∞ not covered Jun 1, 2026 payer document UnitedHealthcare Home Health Care Services (for Kentucky Only) (CS137KY.12) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (CS137.X) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (MP.022.28) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for Kansas Only) (CS137KS.04) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for Nebraska Only) (CS137NE.V) listed, no stance Jan 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for New Jersey Only) (CS137NJ.X) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for New Mexico Only) (CS137NM.D) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for Ohio Only) (CS137OH.E) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Home Health, Skilled, and Custodial Care Services (for Tennessee Only) (CS137TN1.J) listed, no stance Jan 1, 2026 payer document
Recent prior-auth changes Apr 1, 2026: PA removed, UnitedHealthcare Apr 1, 2026: PA removed, UnitedHealthcare Feb 1, 2026: PA added, Humana Jan 1, 2026: PA added, Humana Nov 1, 2025: PA added, Blue Cross and Blue Shield of Illinois Jan 1, 2024: PA removed, humana:pa:commercial Medicaid fee-for-service Prior authorization required or conditional in IN.
KS: $8.50 (default), effective Sep 1, 2002 ND: $12.12 (physician), effective Aug 1, 2026 OK: $6.58 (physician, non-facility), effective Jul 1, 2026 WY: $10.36 (professional), effective Jul 1, 2021 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.