30920 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 30920

Payer coverage policies that name 30920

30920 appears in 4 coverage policies from Aetna, Blue Cross NC.

PayerPolicyRole in policyReviewedDocument
AetnaObstructive Sleep Apnea in Adults (0004)not covered (range 30150-31235)Oct 6, 2026payer document
AetnaObstructive Sleep Apnea in Children (0752)not covered (range 30000-30999)Oct 30, 2025payer document
AetnaTezepelumab-ekko (Tezspire) (1003)listed, no stance (range 30000-31299)Aug 6, 2026payer document
Blue Cross NCProfessional Pathology Billing Requirements AHS – R2169listed, no stance (range 3011F-3210F)Mar 1, 2024payer document

Medicaid fee-for-service

  • AZ: $1188.60 (asc), effective Oct 1, 2026
  • CO: $561.19 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $603.45 (physician, non-facility), effective Jan 1, 2026
  • IL: $590.49 (practitioner), effective Apr 1, 2024
  • IN: $667.19 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $484.96 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $1584.96 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1140.05 (asc), effective May 1, 2026
  • MS: $1270.95 (comprehensive, facility), effective Oct 1, 2025
  • ND: $934.34 (physician, facility), effective Aug 1, 2026
  • NE: $637.00 (asc), effective Jul 1, 2024
  • NY: $390.31 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $549.98 (physician), effective Jan 1, 2024
  • OK: $1446.00 (asc), effective Jan 1, 2026
  • TX: $1118.22 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $672.16 (medical), effective Jul 1, 2026
  • VT: $2451.66 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1396.35 (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.