Payer policies › CPT 2010120101 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 20101 Payer coverage policies that name 20101 20101 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Remote Ischemic Conditioning (0814) listed, no stance (range 20000-29999) Nov 20, 2025 payer document Aetna Skin and Soft Tissue Substitutes (0244) not covered (range 20100-29999) Jul 29, 2026 payer document
Medicaid fee-for-service AZ: $662.63 (asc), effective Oct 1, 2026 CO: $228.61 (chp_plus, non-facility), effective Jul 1, 2026 FL: $156.90 (physician, facility), effective Jan 1, 2026 IL: $210.19 (practitioner), effective Apr 1, 2024 IN: $157.54 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $450.00 (asc, facility), effective Jan 1, 1996 KY: $1101.65 (asc), effective Jan 1, 2026 LA: $443.24 (professional), effective Jul 1, 2025 MA: $155.07 (physician_surgery, facility), effective May 1, 2024 MS: $1566.88 (comprehensive), effective Jul 1, 2026 ND: $685.27 (physician), effective Aug 1, 2026 NE: $151.42 (physician, facility), effective Jul 1, 2026 NY: $96.23 (physician_surgery, facility), effective Jul 1, 2026 OH: $108.84 (physician, facility), effective Jan 1, 2024 OK: $1857.99 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $177.67 (physician, Physician, facility), effective Mar 1, 2026 VA: $174.77 (medical, facility), effective Jul 1, 2026 VT: $1602.06 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $117.34 (physician, facility), effective Jul 1, 2026 WY: $912.46 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026 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.