21490 CPT® code: payer coverage and prior authorization4 of 4 payer prior-auth lists that name 21490 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Humana.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | FEP Blue Focus only | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Aetna | Commercial | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Humana | Humana Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification |
21490 appears in 8 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082) | covered if criteria are met | Mar 18, 2026 | payer document |
| Aetna | General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124) | covered if criteria are met (range 21295-21497) | Mar 19, 2026 | payer 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 |
| Aetna | Temporomandibular Disorders (0028) | covered if criteria are met | Mar 12, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Temporomandibular Joint Disorder | covered if criteria are met | payer document | |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Temporomandibular Joint Disorders (SUR705.010) CPT Codes 20550, 20605, 20606, 21010, 21050, 21060, 21070, 21073, 21076, | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Temporomandibular Joint Disorder (2.01.535) Page | 4 of 20 | ∞ | listed, no stance | Apr 13, 2026 | payer document |
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.