21925 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21925

Payer coverage policies that name 21925

21925 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: $450.44 (asc), effective Oct 1, 2026
  • CO: $304.98 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $289.90 (physician, facility), effective Jan 1, 2026
  • IL: $261.65 (practitioner), effective Apr 1, 2024
  • IN: $292.23 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $247.87 (asc, facility), effective Aug 1, 1982
  • KY: $724.34 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $489.93 (asc), effective May 1, 2026
  • MS: $566.62 (comprehensive, facility), effective Oct 1, 2025
  • ND: $427.00 (physician, facility), effective Aug 1, 2026
  • NE: $552.00 (asc), effective Jul 1, 2024
  • NY: $157.72 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $193.97 (physician, facility), effective Jan 1, 2024
  • OK: $660.83 (asc), effective Jan 1, 2026
  • TX: $486.45 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $322.92 (medical, facility), effective Jul 1, 2026
  • VT: $1282.40 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), 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.