`28289` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 28289

72 of 73 payer prior-auth lists that name 28289 require prior authorization or set conditions: CarePlus Health Plans, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Neighborhood Health Partnership, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Musculoskeletal	All	prior auth required			Humana Prior Authorization List (PAL): Musculoskeletal Services
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required	site of care: site of service reviewed	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	site of care: outpatient hospital	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth under conditions	site of care: outpatient hospital, ASC	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth under conditions	site of care: outpatient hospital	Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth under conditions	site of care: outpatient hospital	Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	North Carolina Medicaid	NC	prior auth required	site of care: site of service reviewed	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth under conditions	site of care: outpatient hospital, ASC	Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	site of care: outpatient hospital	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026

Payer coverage policies that name 28289

28289 appears in 16 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Bunionectomy (0629)	covered if criteria are met	Sep 11, 2026	payer document
Aetna	Bupivacaine Liposome (Exparel) (0941)	listed, no stance (range 28001-28899)	Jul 30, 2026	payer document
Aetna	Nerve Blocks (0863)	listed, no stance (range 28001-28899)	Jul 23, 2026	payer 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
Blue Cross & Blue Shield of Mississippi	Foot Care Services (L.9.01.401)	covered if criteria are met (range 28001-28899)		payer document
Regence	Surgical Site of Care – Hospital Outpatient (Utilization Management 19)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Surgery of the Foot (CS342.K)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Surgery of the Foot (2026T0624O)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Surgery of the Foot (for Idaho Only) (CS342ID.B)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Surgery of the Foot (for Kansas Only) (CS343KS.02)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Surgery of the Foot (for Kentucky Only) (CS342KY.11)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Surgery of the Foot (for New Mexico Only) (CS342NM.D)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Surgery of the Foot (for North Carolina Only) (CSNCT0555.04)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Surgery of the Foot (for Ohio Only) (CS342OH.F)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Surgery of the Foot (for Pennsylvania Only) (CS342PA.I)	listed, no stance	Oct 1, 2025	payer document

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, UnitedHealthcare
Mar 1, 2026: conditions changed, UnitedHealthcare
Jan 1, 2026: conditions changed, UnitedHealthcare
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in WV.

AZ: $1062.88 (asc), effective Oct 1, 2026
CO: $370.01 (chp_plus, non-facility), effective Jul 1, 2026
FL: $341.34 (physician, facility), effective Jan 1, 2026
IL: $359.30 (podiatrist), effective Oct 1, 2014
IN: $363.01 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KY: $1605.64 (asc), effective Jan 1, 2026
LA: $217.00 (asc), effective Jul 1, 2012
MA: $1093.32 (asc), effective May 1, 2026
MS: $1263.33 (comprehensive, facility), effective Oct 1, 2025
ND: $946.52 (physician, facility), effective Aug 1, 2026
NE: $552.00 (asc), effective Jul 1, 2024
NY: $273.51 (physician_surgery, facility), effective Jul 1, 2026
OH: $233.42 (physician, facility), effective Jan 1, 2024
OK: $1464.86 (asc), effective Jan 1, 2026
TX: $1088.27 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $380.21 (medical, facility), 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.

28289 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 28289

Payer coverage policies that name 28289

Recent prior-auth changes

Medicaid fee-for-service

`28289` CPT® code: payer coverage and prior authorization