Payer policies › CPT 2170521705 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 21705 Payer coverage policies that name 21705 21705 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: $3026.13 (asc), effective Oct 1, 2026 CO: $424.53 (chp_plus, non-facility), effective Jul 1, 2026 FL: $384.46 (physician, non-facility), effective Jan 1, 2026 IL: $449.50 (practitioner), effective Jul 1, 2026 IN: $395.28 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $377.78 (default, Exempt Physician), effective Jul 1, 2023 KY: $418.39 (physician, facility), effective Jan 1, 2026 LA: $493.02 (professional), effective Feb 1, 2013 MA: $382.93 (physician_surgery), effective May 1, 2024 MS: $414.14 (comprehensive), effective Jul 1, 2026 ND: $2126.56 (physician, facility), effective Aug 1, 2026 NE: $204.17 (physician, non-facility), effective Jul 1, 2026 NY: $298.89 (physician_surgery, facility), effective Jul 1, 2026 OH: $439.64 (physician), effective Jan 1, 2000 OK: $436.68 (physician, non-facility), effective Jul 1, 2026 TX: $62.61 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Mar 1, 2026 VA: $428.24 (medical), effective Jul 1, 2026 VT: $5634.17 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $282.06 (physician, facility), effective Jul 1, 2026 WY: $3208.96 (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.