Payer policies › CPT 4242042420 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 42420 2 of 2 payer prior-auth lists that name 42420 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth under conditions site of care: outpatient hospital Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
Payer coverage policies that name 42420 42420 appears in 3 coverage policies from Aetna, Regence.
Payer Policy Role in policy Reviewed Document Aetna Intraoperative Neurophysiological Monitoring (0697) covered if criteria are met Jun 19, 2026 payer document Aetna Skin and Soft Tissue Substitutes (0244) listed, no stance (range 42410-42426) Jul 29, 2026 payer document Regence Surgical Site of Care – Hospital Outpatient (Utilization Management 19) listed, no stance May 1, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Medicaid fee-for-service AZ: $1943.46 (asc), effective Oct 1, 2026 CO: $949.32 (chp_plus, non-facility), effective Jul 1, 2026 FL: $822.65 (physician, non-facility), effective Jan 1, 2026 IL: $867.10 (practitioner), effective Jul 1, 2026 IN: $914.93 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $500.00 (asc, facility), effective Aug 1, 1982 KY: $2953.46 (asc), effective Jan 1, 2026 LA: $265.13 (asc), effective Jul 1, 2012 MA: $1909.57 (asc), effective May 1, 2026 MS: $2333.88 (comprehensive, facility), effective Oct 1, 2025 ND: $1741.07 (physician, facility), effective Aug 1, 2026 NE: $1662.00 (asc), effective Jul 1, 2024 NY: $617.12 (physician_surgery, facility), effective Jul 1, 2026 OH: $931.76 (physician), effective Jan 1, 2000 OK: $2694.50 (asc), effective Jan 1, 2026 TX: $1954.22 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $888.60 (medical), effective Jul 1, 2026 VT: $4596.52 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $366.60 (asc), effective Jul 1, 2026 WY: $2617.97 (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.