Payer policies › CPT 2866528665 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 28665 Payer coverage policies that name 28665 28665 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Cigna.
Payer Policy Role in policy Reviewed 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 Cigna Manipulation Under Anesthesia (0276) covered if criteria are met Sep 15, 2026 payer document
Medicaid fee-for-service AZ: $84.24 (asc), effective Oct 1, 2026 CO: $44.90 (chp_plus, non-facility), effective Jul 1, 2026 FL: $93.26 (physician, facility), effective Jan 1, 2026 IL: $117.85 (podiatrist), effective Oct 1, 2014 IN: $99.53 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $190.84 (asc, facility), effective Aug 1, 1982 KY: $149.96 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $98.70 (asc), effective May 1, 2026 MS: $114.02 (comprehensive, facility), effective Oct 1, 2025 ND: $88.40 (physician, facility), effective Aug 1, 2026 NE: $413.00 (asc), effective Jul 1, 2024 NY: $66.85 (physician_surgery, facility), effective Jul 1, 2026 OH: $70.86 (physician, facility), effective Jan 1, 2024 OK: $136.81 (asc), effective Jan 1, 2026 TX: $99.86 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $103.88 (medical, facility), effective Jul 1, 2026 VT: $217.17 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $308.28 (asc), effective Jul 1, 2026 WY: $123.69 (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.