42890 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42890

Payer coverage policies that name 42890

42890 appears in 2 coverage policies from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaObstructive Sleep Apnea in Adults (0004)not coveredOct 6, 2026payer document
AetnaObstructive Sleep Apnea in Children (0752)listed, no stance (range 42700-42999)Oct 30, 2025payer document
AetnaObstructive Sleep Apnea in Children (0752)not coveredOct 30, 2025payer document

Medicaid fee-for-service

  • AZ: $1943.46 (asc), effective Oct 1, 2026
  • CO: $1145.42 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $976.22 (physician, non-facility), effective Jan 1, 2026
  • IL: $958.60 (practitioner), effective Jul 1, 2026
  • IN: $1082.22 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $300.00 (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: $649.49 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $745.08 (physician), effective Jan 1, 2024
  • 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: $1087.38 (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.