Payer policies › CPT 3690436904 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 36904 Payer coverage policies that name 36904 36904 appears in 7 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Anesthetic and Antiemetic Infusion Pumps (0607) listed, no stance (range 33016-37799) Sep 9, 2026 payer document Aetna Bupivacaine Liposome (Exparel) (0941) listed, no stance (range 33010-37799) Jul 30, 2026 payer document Aetna Cardiovascular Ultrafiltration (0741) listed, no stance (range 33010-37790) Oct 30, 2025 payer document Aetna Negative Pressure Wound Therapy (0334) listed, no stance (range 33016-37799) Jun 8, 2026 payer document Aetna Nitric Oxide, Inhalational (INO) (0518) not covered (range 33016-37790) Jul 2, 2026 payer document Aetna Stereolithographic Models and Implants (0613) listed, no stance (range 33010-37790) Sep 3, 2026 payer document Aetna Thrombectomy Systems (0568) covered if criteria are met (range 36904-36906) Sep 18, 2026 payer document
Medicaid fee-for-service AZ: $2843.41 (asc), effective Oct 1, 2026 CO: $353.87 (chp_plus, non-facility), effective Jul 1, 2026 FL: $249.38 (physician, facility), effective Jan 1, 2026 IL: $251.26 (practitioner), effective Apr 1, 2024 IN: $275.63 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $1939.20 (asc, facility), effective Jan 1, 2017 KY: $3535.00 (asc), effective Jan 1, 2026 LA: $233.58 (asc), effective Jan 1, 2017 MA: $2443.95 (asc), effective May 1, 2026 MS: $2812.66 (comprehensive, facility), effective Oct 1, 2025 ND: $2083.89 (physician, facility), effective Aug 1, 2026 NE: $296.40 (physician, non-facility), effective Jul 1, 2026 NY: $191.34 (physician_surgery, facility), effective Jul 1, 2026 OH: $278.83 (physician, facility), effective Jan 1, 2024 OK: $3225.05 (asc), effective Jan 1, 2026 TX: $2362.78 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $277.78 (medical, facility), effective Jul 1, 2026 VT: $4419.28 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $366.60 (asc), effective Jul 1, 2026 WY: $2517.02 (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.