`42299` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42299

55 of 55 payer prior-auth lists that name 42299 require prior authorization or set conditions: Aetna, Blue Shield of California, CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California	Blue Shield Medicare	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield Medicare
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required	site of care: procedure and site of service review	Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Other Services	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Other Services
Cigna	Other Services	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth under conditions	only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890	Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth required		Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth required		Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth required		Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Nov 1, 2025	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U

Payer coverage policies that name 42299

42299 appears in 10 coverage policies from Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence.

Payer	Policy	Role in policy	Reviewed	Document
Anthem	Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring (SURG.00129)	unproven / investigational	Aug 13, 2026	payer document
Anthem	Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring (SURG.00129)	not covered	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Sleep Disorders (L.2.01.415)	not covered		payer document
Blue Cross NC	Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome	listed, no stance	Mar 1, 2026	payer document
Blue Shield of California	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.101)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (CAM 701101) 21685 \| Hyoid myotomy and suspension	listed, no stance	Jul 1, 2026	payer document
Capital Blue Cross	Surgical Treatment of Sleep Apnea and Snoring (MP 1.128) Procedure codes	unproven / investigational	Apr 1, 2026	payer document
Cigna	Surgical Treatments for Obstructive Sleep Apnea (0158)	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Sleep Related Breathing Disorders: Surgical Management (SUR706.009) CPT Codes 21083, 21085, 21127, 21141, 21142, 21143, 21193, 21194, 21195,	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.554) Page \| 8 of 33 \| ∞	listed, no stance	Jul 27, 2026	payer document
Regence	Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (Surgery 166)	listed, no stance	Dec 1, 2025	payer document

Recent prior-auth changes

Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, Oxford Health Plans
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in FL, KY, VT, WV, WY.

AZ: $153.41 (outpatient_hospital), effective Oct 1, 2021
FL: $269.52 (physician, non-facility), effective Jan 1, 2026
IN: $0.00 (professional, facility), effective Jan 1, 2010
KY: $0.00 (physician, facility), effective Jan 1, 2026
MS: $179.87 (comprehensive), effective Jul 1, 2026
ND: $0.00 (physician), effective Aug 1, 2026
OK: $0.00 (physician, non-facility), effective Jul 1, 2026
TX: $0.00 (certified_nurse_midwife_cnm, Certified Nurse Midwife (Cnm), facility), effective Dec 18, 1976
VT: $183.90 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $104.75 (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.

42299 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42299

Payer coverage policies that name 42299

Recent prior-auth changes

Medicaid fee-for-service

`42299` CPT® code: payer coverage and prior authorization