PA Check — Prior Authorization Lookup
for Any CPT Code & Any Insurer

What Is Prior Authorization? (And Why It Matters More in 2026)

Prior authorization — also called “prior auth,” “PA,” “pre-authorization,” or “pre-certification” — is a requirement from health insurers that providers obtain payer approval before delivering certain medical services, procedures, or medications. It is the insurer’s mechanism to confirm a proposed service meets their coverage criteria before they commit to paying for it.

Whether a CPT code requires PA depends on three variables: the insurance company, the patient’s specific plan, and the place of service. CPT 27447 (total knee arthroplasty) requires PA from Anthem at every facility type but not from traditional Medicare FFS in any setting. The same MRI brain scan (CPT 70553) requires PA from UHC commercial plans and most Medicare Advantage plans — but not traditional Medicare.

Physicians and their staff spend an average of 13 hours per week completing PA requests — more than one full workday every week. For a four-physician practice, that exceeds 2,700 staff hours annually absorbed by administrative overhead rather than patient care.

The True Cost of Prior Authorization — Beyond the Paperwork

The administrative cost of PA is well-documented, but the clinical cost is what keeps physicians up at night. A 2024 survey by the Kaiser Family Foundation found that 40% of physicians reported a patient experienced a serious adverse event — including hospitalization or permanent disability — because a PA delay prevented timely care. These are not edge cases. They represent a systemic failure happening across every specialty in every state.

For surgical specialties, the burden hits hardest. Orthopedic surgeons booking total joint replacements, spine surgeons scheduling lumbar fusions, and cardiac surgeons booking TAVR procedures all face PA timelines that can stretch 10 to 21 days — with denial rates as high as 37% from the most restrictive payers. Every denial that goes unappealed costs the practice roughly $94 in administrative overhead and costs the patient real time.

How to Use the PA Check Tool — Step-by-Step

The PA Check tool at the top of this page gives physicians, medical assistants, and billing staff instant prior authorization guidance for any CPT or HCPCS code across 30+ major US insurers — in under one second, with no login required.

1. 1
   Enter the CPT or HCPCS Code Type the exact procedure code: CPT codes (5-digit numeric), HCPCS Level II (letter + 4 digits), or Category III codes. Examples: 27447 (total knee arthroplasty), 70553 (MRI brain w/ and w/o contrast), J0129 (Abatacept/Orencia), E0601 (CPAP device).
2. 2
   Select the Insurance Company For Medicare Advantage patients, always select “Medicare Advantage” — not “Medicare (Traditional FFS)” — because MA plans have entirely different PA requirements. Check the patient’s card: if a private insurer logo appears alongside Medicare, that’s Medicare Advantage.
3. 3
   Select a Specialty (Strongly Recommended) Selecting a specialty displays quick-access CPT chips for that discipline and improves PA data accuracy. Use the chips to check multiple codes in seconds without retyping.
4. 4
   Select Place of Service Critical for Medicare. PA requirements differ between outpatient hospital (POS 22), ASC (POS 24), and office (POS 11). The Medicare CMS OPD PA program requires PA for specific procedures only in the outpatient hospital setting — the same procedure in an ASC does not trigger the PA requirement.
5. 5
   Review Results and Act Results show PA status, turnaround time, approval rate, submitting vendor, and documentation tips for that specialty-payer combination. Always verify directly with the payer before scheduling — PA requirements change monthly at some payers.

Prior Authorization Requirements by Specialty — 2026 Edition

Different specialties face dramatically different PA burdens. Understanding payer requirements for your specialty — and the documentation triggers that drive approvals versus denials — is the foundation of efficient PA management.

Orthopedics & Spine Surgery

Orthopedic and spine surgery carry the highest PA burden of any specialty. For total joint replacement (CPT 27447, 27130) and spinal fusion (CPT 22612, 22551), virtually every commercial payer requires PA. Approval rates range from 63% (Anthem/spine) to 76% (Humana/orthopedics). The single most common denial reason — across every payer — is insufficient conservative care documentation. Payers want 3 months of documented conservative care for joint replacement and 6 months for spinal fusion, with specific therapy, injection, and medication records. Including functional outcome scores — KOOS/WOMAC for knee, HOOS for hip, Oswestry for spine — directly addresses payer criteria and measurably improves approval rates.

Radiology & Advanced Imaging

MRI, CT, and PET/CT require PA from virtually all commercial payers and most Medicare Advantage plans. Traditional Medicare FFS does NOT require PA for imaging. Most commercial payers route imaging PA through Evicore, Carelon (formerly AIM), or Evolent/RadMD. Turnaround is typically 1–3 days with portal submission, making imaging one of the faster PA categories. UHC’s AIM portal, Aetna’s Evicore portal, and Regence/Premera’s Carelon portal all support real-time or same-day decisions for well-documented cases.

Cardiology & Cardiac Devices

In a 2025 policy change, United Healthcare eliminated PA for echocardiography and nuclear cardiology imaging on commercial plans — a significant reduction for cardiologists. TAVR (CPT 33361), CABG (CPT 33533–33536), PCI (CPT 92920–92944), and all cardiac device implantation — pacemakers, ICDs, S-ICDs, CardioMEMS, LINQ — continue to require PA from all major payers. Average approval rates for cardiac procedures run 79–85%, higher than surgical specialties due to the strong objective clinical documentation available.

Behavioral Health & Psychiatry

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that behavioral health PA standards be no more restrictive than medical/surgical standards — but enforcement remains inconsistent. TMS (CPT 90867–90869), ABA therapy (CPT 97151–97157), ECT (CPT 90870), partial hospitalization, and residential treatment consistently require PA. Routine outpatient psychotherapy typically does not, but ongoing session counts trigger concurrent review at most commercial payers at 8–12 sessions.

Oncology & CAR-T Cell Therapy

Chemotherapy infusion (CPT 96413, 96415), radiation therapy (IMRT: CPT 77385–77386, SBRT: CPT 77373), and all systemic oncology drugs require PA from every major payer. CAR-T cell therapies (CPT 0537T–0540T, Q2055) require PA with 10–21 day review periods handled by dedicated payer transplant or specialty pharmacy programs. Staging PET/CT (CPT 78816) requires PA from commercial payers but not traditional Medicare.

Prior Authorization by Insurance Company — What You Actually Need to Know

Not all insurers carry equal PA burden. The spectrum runs from traditional Medicare (lowest PA burden) to Anthem/Elevance and Centene/Ambetter (highest denial rates and broadest requirements). Here is what matters for each major payer category in 2026.

United Healthcare (UHC) — Vendor: AIM Specialty Health

UHC is the largest commercial insurer in the US. They made notable reductions in 2025–2026, eliminating PA for echocardiography and nuclear cardiology imaging on commercial plans. For surgical procedures — orthopedics, spine, bariatric — UHC uses AIM Specialty Health (uhcprovider.com). AIM’s portal enables real-time decisions for straightforward, well-documented cases. UHC applies InterQual criteria for medical necessity. A gold card program exists for providers with 90%+ historical approval rates — contact your UHC provider advocate to assess eligibility.

Anthem / Elevance Health — Vendor: AIM Specialty Health

Anthem consistently ranks as the payer with the broadest PA requirements and highest denial rates in our dataset. All Anthem submissions route through AIM via Availity (availity.com). The gold card program at Anthem is real and worth pursuing if your practice has sufficient volume. For spine surgery, some Anthem plans require a pre-surgical psychological evaluation before approving lumbar fusion — worth anticipating early.

Florida Blue (GuideWell) — Radiology Vendor: Evolent/RadMD

Florida Blue uses a split PA infrastructure. Radiology PA (MRI, CT, PET, cardiac imaging) routes through Evolent/RadMD at 1-888-642-2583. Surgical and musculoskeletal PA also routes through Evolent, submitted via Availity. Florida Blue requires PA for advanced imaging, orthopedic surgery, behavioral health admissions, home health, DME, specialty drugs, and bariatric surgery.

Premera Blue Cross & Regence — Shared Vendor: Carelon

Both Premera (Washington and Alaska) and Regence (WA, OR, ID, UT) use Carelon (formerly AIM Specialty Health) for cardiovascular, radiology, musculoskeletal, and sleep medicine PA. This is operationally significant: one portal serves both payers. Both update their PA requirement lists monthly — making this one of the most important categories to reverify regularly.

CareSource — Medicaid Managed Care Across 8 States

CareSource operates Medicaid and Marketplace plans in Ohio, Georgia, Indiana, Kentucky, West Virginia, Missouri, North Carolina, and additional markets. As a Medicaid MCO, CareSource applies stringent PA requirements for surgical procedures, behavioral health, and specialty medications. Submit via Availity or the CareSource provider portal (1-800-488-0134).

Independence Blue Cross — Vendor: AIM Specialty Health

Independence Blue Cross, serving the Philadelphia area, uses AIM Specialty Health for imaging and musculoskeletal PA programs. IBC requires PA for inpatient admissions, surgical procedures, advanced imaging, behavioral health, specialty drugs, home health, and DME. Access via Availity.

Traditional Medicare — Lowest PA Burden, but OPD Rules Apply

Traditional Medicare FFS does not require PA for the vast majority of clinical services. However, the CMS OPD PA program requires PA for specific procedures performed in outpatient hospital settings: blepharoplasty (CPT 15820–15822), rhinoplasty (CPT 30400–30420), panniculectomy (CPT 15830), vein ablation, spinal neurostimulators, cervical fusion with disc removal, facet joint interventions, and botulinum toxin. These procedures do NOT require PA when performed in an ASC or physician office — only in the outpatient hospital setting.

7 Evidence-Based Strategies to Get Prior Authorization Approved

2026 PA Reform Rules: What Changed and What It Means for Your Practice

Peer-to-Peer Review: The Most Underused PA Reversal Tool

Peer-to-peer (P2P) review is the process where the treating physician speaks directly — typically by phone — with the payer’s medical director or reviewing physician to discuss a denied or pending PA. It is the single most effective first-line tool for overturning PA denials, with documented overturn rates of 60–80% across surgical specialties.

1. Request within the deadline. Most payers require P2P requests within 30–60 days of the denial date. Check the denial letter for the specific deadline.
2. Specifically request a peer-to-peer review. Call the PA department and use the words “peer-to-peer review.” P2P and formal appeal are different processes.
3. Request a same-specialty reviewer. Under the 2026 AHIP voluntary commitments, you have the right to request a reviewer in the same or related specialty.
4. Prepare your clinical talking points before the call. Know which specific criteria the payer cited for denial and address each with objective clinical data.
5. Document the call completely. Date, time, reviewer name, their specialty, what was said, and outcome.

Gold Card Programs: PA Exemptions for High-Performing Providers

A gold card program exempts providers with a consistently high PA approval rate from routine PA requirements for certain procedure categories. As of June 2026, the following major payers offer gold card programs:

Medicare vs. Commercial Prior Authorization: Key Differences Every Practice Must Know

A practical identification rule: if the patient’s card shows only the red, white, and blue Medicare design with a Medicare Beneficiary Identifier (MBI number), that’s traditional Medicare FFS. If there’s a private insurer logo alongside the Medicare logo, that’s Medicare Advantage — verify PA requirements before scheduling anything beyond a routine office visit.

More Prior Authorization Questions — Answered