25259 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 25259

5 of 5 payer prior-auth lists that name 25259 require prior authorization or set conditions: Cigna, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsAug 17, 2009Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsAug 17, 2009Master Precertification List (For Health Care Providers)
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
CignaMusculoskeletalAllprior auth requiredMar 7, 2026Cigna Commercial Prior Authorization Procedure Code List: Musculoskeletal - Joint Surgery
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJan 1, 2015Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U

Payer coverage policies that name 25259

25259 appears in 20 coverage policies from Aetna, Anthem, Cigna, Regence, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaIntraoperative Neurophysiological Monitoring (0697)not covered (range 25000-25999)Jun 19, 2026payer document
AetnaManipulation Under General Anesthesia (0204)not coveredMar 25, 2026payer document
AetnaNerve Blocks (0863)listed, no stance (range 25000-25999)Jul 23, 2026payer document
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
AnthemManipulation Under Anesthesia (CG-MED-65)not coveredAug 13, 2026payer document
CignaManipulation Under Anesthesia (0276)covered if criteria are metSep 15, 2026payer document
CignaManipulation Under Anesthesia (0276)not coveredSep 15, 2026payer document
RegenceManipulation Under Anesthesia (Medicine 130)listed, no stanceOct 1, 2025payer document
UnitedHealthcareManipulation Under Anesthesia (CS075.U)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (2026T0515CC)listed, no stanceFeb 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Idaho Only) (CS075ID.C)listed, no stanceJun 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Kansas Only) (CS075KS.02)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Kentucky Only) (CS075KY.07)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Nebraska Only) (CS075NE.U)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for New Jersey Only) (CS075NJ.P)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for New Mexico Only) (CS075NM.C)listed, no stanceMar 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for North Carolina Only) (CSNCT0515.04)listed, no stanceApr 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Ohio Only) (CS075OH.D)listed, no stanceApr 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Pennsylvania Only) (CS075PA.R)listed, no stanceApr 1, 2026payer document
UnitedHealthcareManipulation Under Anesthesia (for Tennessee Only) (CS075TN.R)listed, no stanceMar 1, 2026payer document

Recent prior-auth changes

  • Oct 1, 2026: PA removed, Oxford Health Plans

Medicaid fee-for-service

  • AZ: $504.49 (asc), effective Oct 1, 2026
  • CO: $357.25 (chp_plus, non-facility), effective Jul 1, 2026
  • IL: $295.38 (practitioner), effective Apr 1, 2024
  • IN: $332.19 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $244.53 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $852.05 (asc), effective Jan 1, 2026
  • LA: $348.75 (professional), effective Jul 1, 2025
  • MA: $606.05 (asc), effective May 1, 2026
  • MS: $670.63 (comprehensive, facility), effective Oct 1, 2025
  • ND: $502.29 (physician, facility), effective Aug 1, 2026
  • NE: $370.50 (physician, non-facility), effective Jul 1, 2026
  • NY: $190.73 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $263.69 (physician), effective Jan 1, 2024
  • OK: $375.88 (physician, non-facility), effective Jul 1, 2026
  • TX: $593.04 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $378.76 (medical), effective Jul 1, 2026
  • VT: $1248.54 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $711.11 (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.