Payer policies › CPT 4295042950 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 42950 11 of 11 payer prior-auth lists that name 42950 require prior authorization or set conditions: CarePlus Health Plans, Humana.
Payer Plan State Prior auth Conditions Since Source 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
Payer coverage policies that name 42950 42950 appears in 7 coverage policies from Aetna, Blue Cross NC, Blue Shield of California, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
Payer Policy Role in policy Reviewed Document Aetna Obstructive Sleep Apnea in Adults (0004) not covered Oct 6, 2026 payer document Aetna Obstructive Sleep Apnea in Children (0752) listed, no stance (range 42700-42999) Oct 30, 2025 payer document Aetna Obstructive Sleep Apnea in Children (0752) not covered Oct 30, 2025 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 Capital Blue Cross Surgical Treatment of Sleep Apnea and Snoring (MP 1.128)Procedure codes covered if criteria are met Apr 1, 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
Recent prior-auth changes Dec 31, 2024: PA removed, Cigna Dec 31, 2024: PA removed, Cigna Medicaid fee-for-service AZ: $1943.46 (asc), effective Oct 1, 2026 CO: $653.25 (chp_plus, non-facility), effective Jul 1, 2026 FL: $570.20 (physician, non-facility), effective Jan 1, 2026 IL: $758.08 (practitioner), effective Apr 1, 2024 IN: $609.33 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $273.15 (asc, facility), effective Aug 1, 1982 KY: $2953.46 (asc), effective Jan 1, 2026 LA: $182.30 (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: $391.45 (physician_surgery, facility), effective Jul 1, 2026 OH: $478.88 (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: $635.13 (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.