Payer policies › CPT 3090130901 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 30901 Payer coverage policies that name 30901 30901 appears in 4 coverage policies from Aetna, Blue Cross NC.
Payer Policy Role in policy Reviewed Document Aetna Obstructive Sleep Apnea in Adults (0004) not covered (range 30150-31235) Oct 6, 2026 payer document Aetna Obstructive Sleep Apnea in Children (0752) not covered (range 30000-30999) Oct 30, 2025 payer document Aetna Tezepelumab-ekko (Tezspire) (1003) listed, no stance (range 30000-31299) Aug 6, 2026 payer document Blue Cross NC Professional Pathology Billing Requirements AHS – R2169 listed, no stance (range 3011F-3210F) Mar 1, 2024 payer document
Medicaid fee-for-service AZ: $105.14 (outpatient_hospital, RF133), effective Oct 1, 2024 CO: $79.28 (chp_plus, non-facility), effective Jul 1, 2026 FL: $38.84 (physician, facility), effective Jan 1, 2026 IL: $56.56 (practitioner), effective Apr 1, 2024 IN: $43.04 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $225.00 (asc, facility), effective Aug 1, 1982 KY: $0.00 (asc), effective Jan 1, 2026 LA: $121.41 (professional), effective Jul 1, 2025 MA: $0.00 (asc), effective May 1, 2026 MS: $132.15 (comprehensive), effective Jul 1, 2026 ND: $182.11 (physician), effective Aug 1, 2026 NE: $69.34 (physician, facility), effective Jul 1, 2026 NY: $29.37 (physician_surgery, facility), effective Jul 1, 2026 OH: $28.90 (physician, facility), effective Jan 1, 2024 OK: $44.50 (physician, facility), effective Jul 1, 2026 TX: $36.64 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026 VA: $43.11 (medical, facility), effective Jul 1, 2026 VT: $103.31 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $28.67 (physician, facility), effective Jul 1, 2026 WY: $58.84 (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.