Payer policies › CPT 2849528495 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 28495 Payer coverage policies that name 28495 28495 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.
Payer Policy Role in policy Reviewed Document Aetna Bupivacaine Liposome (Exparel) (0941) listed, no stance (range 28001-28899) Jul 30, 2026 payer document Aetna Negative Pressure Wound Therapy (0334) listed, no stance (range 28400-28531) Jun 8, 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
Medicaid fee-for-service AZ: $73.83 (asc), effective Oct 1, 2026 CO: $122.30 (chp_plus, non-facility), effective Jul 1, 2026 FL: $120.01 (physician, facility), effective Jan 1, 2026 IL: $69.30 (podiatrist), effective Apr 1, 2024 IN: $120.58 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $65.53 (asc, facility), effective Jul 1, 1987 KY: $131.72 (asc), effective Jan 1, 2026 LA: $144.80 (professional), effective Jul 1, 2025 MA: $92.62 (asc), effective May 1, 2026 MS: $97.82 (comprehensive, facility), effective Oct 1, 2025 ND: $130.29 (physician, facility), effective Aug 1, 2026 NE: $58.41 (physician, facility), effective Jul 1, 2026 NY: $72.48 (physician_surgery, facility), effective Jul 1, 2026 OH: $76.31 (physician, facility), effective Jan 1, 2024 OK: $133.79 (physician, facility), effective Jul 1, 2026 TX: $85.32 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $133.68 (medical, facility), effective Jul 1, 2026 VT: $191.53 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $93.64 (physician, facility), effective Jul 1, 2026 WY: $109.09 (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.