What documentation does Cigna require for CPT 64612?

Clinical notes supporting medical necessity; Relevant diagnostic, imaging, lab, or treatment records for the requested service

How much does Medicare pay for CPT 64612 in 2026?

In 2026, the national Medicare allowable for CPT 64612 is $141.62 in an office setting and $108.22 in a facility. Commercial allowables for Cigna are typically negotiated against this benchmark.

What if Cigna denies the PA for CPT 64612?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Cigna Prior Authorization for CPT 64612

Chemodenervation of salivary glands and facial/cervical muscles (eg, blepharospasm, hemifacial spasm, chronic migraine) · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified May 9, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Cigna Master Precertification List for Providers - May 2026

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Cigna Master Precertification List for Providers identifies 64612 as requiring prior authorization for both Complete/PHS+/Preferred and Basic Standard commercial care management models, effective 2006-10-01. Confirm member benefit, plan model, and delegated workflow before submission.

Documentation checklist

✓Clinical notes supporting medical necessity
✓Relevant diagnostic, imaging, lab, or treatment records for the requested service

2026 Medicare rate for CPT 64612

Office (non-facility)

$141.62

Facility

$108.22

Total RVUs (office)

4.24

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Cigna's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 64612 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Clinical notes supporting medical necessity, Relevant diagnostic, imaging, lab, or treatment records for the requested service.
3Submit via the payer's provider portal or designated PA channel.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Cigna require prior authorization for CPT 64612?: Yes. Cigna requires prior authorization for CPT 64612 (Chemodenervation of salivary glands and facial/cervical muscles (eg, blepharospasm, hemifacial spasm, chronic migraine)) under Standard commercial plans per its published clinical policy.
What documentation does Cigna require for CPT 64612?: Clinical notes supporting medical necessity; Relevant diagnostic, imaging, lab, or treatment records for the requested service
How much does Medicare pay for CPT 64612 in 2026?: In 2026, the national Medicare allowable for CPT 64612 is $141.62 in an office setting and $108.22 in a facility. Commercial allowables for Cigna are typically negotiated against this benchmark.
What if Cigna denies the PA for CPT 64612?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Cigna PA lookups

CPT 17110 CPT 45380 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235

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CPT 64612 prior authorization by payer

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