42830 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42830

18 of 18 payer prior-auth lists that name 42830 require prior authorization or set conditions: UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
UnitedHealthcare Community PlanAHCCCS Complete Care (ACC)AZprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community PlanALTCS Developmentally DisabledAZprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth under conditionssite of care: outpatient hospitalSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO) and OneCareMAprior auth requiredOct 1, 2026Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community PlanMississippi CHIPMSprior auth under conditionssite of care: outpatient hospitalApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth under conditionssite of care: outpatient hospitalApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community PlanMissouri MedicaidMOprior auth under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth under conditionssite of care: outpatient hospital, ASCNov 1, 2025Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community PlanPennsylvania CHIPPAprior auth under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth under conditionssite of care: outpatient hospitalMay 1, 2026Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community PlanTennCareTNprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth under conditionssite of care: outpatient hospitalJul 1, 2020Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community PlanTexas STARTXprior auth under conditionssite of care: outpatient hospitalJul 1, 2020Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community PlanTexas STAR KidsTXprior auth under conditionssite of care: outpatient hospitalJul 1, 2020Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community PlanTexas STAR+PLUSTXprior auth under conditionssite of care: outpatient hospitalJul 1, 2020Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023

Payer coverage policies that name 42830

42830 appears in 10 coverage policies from Aetna, Anthem, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross.

PayerPolicyRole in policyReviewedDocument
AetnaEnuresis (0431)not coveredJul 1, 2026payer document
AetnaMyringotomy and Tympanostomy Tube (0418)listed, no stance (range 42830-42836)Jun 30, 2026payer document
AetnaObstructive Sleep Apnea in Children (0752)covered if criteria are met (range 42830-42831)Oct 30, 2025payer document
AetnaObstructive Sleep Apnea in Children (0752)listed, no stance (range 42700-42999)Oct 30, 2025payer document
AetnaSinus Surgeries (0937)listed, no stanceApr 10, 2026payer document
AnthemAdenoidectomy (CG-SURG-36)covered if criteria are metFeb 19, 2026payer document
Blue Cross Blue Shield of MassachusettsSurgical treatment of Snoring and Obstructive Sleep Apnea Syndrome (130)listed, no stancepayer document
Blue Cross NCSurgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndromelisted, no stanceMar 1, 2026payer document
Blue Shield of CaliforniaSurgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.101)listed, no stancepayer document
BlueCross BlueShield of South CarolinaSurgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (CAM 701101)
21685 | Hyoid myotomy and suspension		listed, no stance (range 42830-42831)Jul 1, 2026payer document
Capital Blue CrossSurgical Treatment of Sleep Apnea and Snoring (MP 1.128)
Procedure codes		covered if criteria are metApr 1, 2026payer document

Recent prior-auth changes

  • Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
  • Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
  • Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
  • Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in WV.

  • AZ: $926.87 (asc), effective Oct 1, 2026
  • CO: $172.88 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $151.97 (physician, non-facility), effective Jan 1, 2026
  • IL: $145.20 (practitioner), effective Apr 1, 2024
  • IN: $166.53 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $385.00 (asc, facility), effective Aug 1, 1982
  • KY: $1445.19 (asc), effective Jan 1, 2026
  • LA: $265.13 (asc), effective Jul 1, 2012
  • MA: $896.80 (asc), effective May 1, 2026
  • MS: $1115.56 (comprehensive, facility), effective Oct 1, 2025
  • ND: $851.94 (physician, facility), effective Aug 1, 2026
  • NE: $1662.00 (asc), effective Jul 1, 2024
  • NY: $100.23 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $132.46 (physician), effective Jan 1, 2024
  • OK: $1318.48 (asc), effective Jan 1, 2026
  • TX: $886.62 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $169.27 (medical), effective Jul 1, 2026
  • VT: $2574.33 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1466.22 (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.