25420 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 25420

Payer coverage policies that name 25420

25420 appears in 4 coverage policies from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaIntraoperative Neurophysiological Monitoring (0697)not covered (range 25000-25999)Jun 19, 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

Medicaid fee-for-service

  • AZ: $3810.74 (asc), effective Oct 1, 2026
  • CO: $748.26 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $831.01 (physician, non-facility), effective Jan 1, 2026
  • IL: $839.35 (practitioner), effective Jul 1, 2026
  • IN: $894.40 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $400.00 (asc, facility), effective Aug 1, 1982
  • KY: $5007.17 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $2382.86 (asc), effective May 1, 2026
  • MS: $3559.90 (comprehensive, facility), effective Oct 1, 2025
  • ND: $2951.73 (physician, facility), effective Aug 1, 2026
  • NE: $1662.00 (asc), effective Jul 1, 2024
  • NY: $631.84 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $917.58 (physician), effective Jan 1, 2024
  • OK: $4568.15 (asc), effective Jan 1, 2026
  • TX: $3431.78 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $925.64 (medical), effective Jul 1, 2026
  • VT: $5634.17 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $446.73 (asc), 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.