21558 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21558

Payer coverage policies that name 21558

21558 appears in 2 coverage policies from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaRemote Ischemic Conditioning (0814)listed, no stance (range 20000-29999)Nov 20, 2025payer document
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 20100-29999)Jul 29, 2026payer document

Medicaid fee-for-service

  • AZ: $751.83 (asc), effective Oct 1, 2026
  • CO: $1063.65 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $949.98 (physician, non-facility), effective Jan 1, 2026
  • IL: $934.79 (practitioner), effective Apr 1, 2024
  • IN: $1016.90 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $609.00 (asc, facility), effective Jan 1, 2010
  • KY: $1218.59 (asc), effective Jan 1, 2026
  • LA: $1130.56 (professional), effective Feb 1, 2013
  • MA: $845.19 (asc), effective May 1, 2026
  • MS: $961.52 (comprehensive, facility), effective Oct 1, 2025
  • ND: $718.36 (physician, facility), effective Aug 1, 2026
  • NE: $785.00 (asc), effective Jul 1, 2024
  • NY: $695.76 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $802.42 (physician), effective Jan 1, 2024
  • OK: $1111.74 (asc), effective Jan 1, 2026
  • TX: $815.20 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $1058.16 (medical), effective Jul 1, 2026
  • VT: $2255.40 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1284.57 (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.