Payer policies › CPT 2192021920 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 21920 2 of 2 payer prior-auth lists that name 21920 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth under conditions site of care: outpatient hospital Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
Payer coverage policies that name 21920 21920 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
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Jun 1, 2026: conditions changed, UnitedHealthcare Apr 1, 2026: PA removed, UnitedHealthcare Community Plan Medicaid fee-for-service AZ: $101.75 (asc), effective Oct 1, 2026 CO: $124.66 (chp_plus, non-facility), effective Jul 1, 2026 FL: $110.66 (physician, facility), effective Jan 1, 2026 IL: $113.50 (practitioner), effective Jul 1, 2026 IN: $119.59 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $203.40 (asc, facility), effective Aug 1, 1982 KY: $181.52 (asc), effective Jan 1, 2026 LA: $200.98 (professional), effective Jul 1, 2025 MA: $151.23 (asc), effective May 1, 2026 MS: $134.30 (comprehensive, facility), effective Oct 1, 2025 ND: $179.55 (physician, facility), effective Aug 1, 2026 NE: $413.00 (asc), effective Jul 1, 2024 NY: $73.14 (physician_surgery, facility), effective Jul 1, 2026 OH: $87.44 (physician, facility), effective Jan 1, 2024 OK: $124.77 (physician, facility), effective Jul 1, 2026 TX: $148.39 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $123.26 (medical, facility), effective Jul 1, 2026 VT: $1282.40 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $84.85 (physician, facility), effective Jul 1, 2026 WY: $730.40 (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.