Payer policies › CPT 4280942809 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 42809 Payer coverage policies that name 42809 42809 appears in 1 coverage policy from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Obstructive Sleep Apnea in Children (0752) listed, no stance (range 42700-42999) Oct 30, 2025 payer document
Medicaid fee-for-service AZ: $79.50 (outpatient_hospital, RF133), effective Oct 1, 2025 CO: $101.57 (chp_plus, non-facility), effective Jul 1, 2026 FL: $90.92 (physician, facility), effective Jan 1, 2026 IL: $124.64 (practitioner), effective Apr 1, 2024 IN: $97.34 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $231.00 (asc, facility), effective Aug 1, 1982 KY: $0.00 (asc), effective Jan 1, 2026 LA: $163.17 (professional), effective Jul 1, 2025 MA: $0.00 (asc), effective May 1, 2026 MS: $339.25 (comprehensive), effective Jul 1, 2026 ND: $234.68 (physician), effective Aug 1, 2026 NE: $15.05 (physician, facility), effective Jul 1, 2026 NY: $61.77 (physician_surgery, facility), effective Jul 1, 2026 OH: $82.65 (physician, facility), effective Jan 1, 2024 OK: $402.28 (outpatient_hospital_apc), effective Jan 1, 2026 TX: $90.38 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Sep 1, 2026 VA: $101.27 (medical, facility), effective Jul 1, 2026 VT: $346.86 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $69.37 (physician, facility), effective Jul 1, 2026 WY: $197.56 (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.