25426 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 25426

Payer coverage policies that name 25426

25426 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: $1349.78 (asc), effective Oct 1, 2026
  • CO: $636.02 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $798.80 (physician, non-facility), effective Jan 1, 2026
  • IL: $778.58 (practitioner), effective Apr 1, 2024
  • IN: $860.86 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $600.00 (asc, facility), effective Aug 1, 1982
  • KY: $2117.47 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1093.32 (asc), effective May 1, 2026
  • MS: $1666.74 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1248.25 (physician, facility), effective Aug 1, 2026
  • NE: $1233.00 (asc), effective Jul 1, 2024
  • NY: $595.09 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $799.26 (physician), effective Jan 1, 2000
  • OK: $1931.82 (asc), effective Jan 1, 2026
  • TX: $1480.46 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $889.76 (medical), effective Jul 1, 2026
  • VT: $2540.58 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1447.00 (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.