42955 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 42955

Payer coverage policies that name 42955

42955 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaObstructive Sleep Apnea in Children (0752)listed, no stance (range 42700-42999)Oct 30, 2025payer document

Medicaid fee-for-service

  • AZ: $396.13 (asc), effective Oct 1, 2026
  • CO: $187.05 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $541.88 (physician, non-facility), effective Jan 1, 2026
  • IL: $505.87 (practitioner), effective Apr 1, 2024
  • IN: $579.96 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $446.45 (default, Exempt Physician), effective Aug 1, 2024
  • KY: $643.45 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $456.11 (asc), effective May 1, 2026
  • MS: $525.90 (comprehensive, facility), effective Oct 1, 2025
  • ND: $379.31 (physician, facility), effective Aug 1, 2026
  • NE: $637.00 (asc), effective Jul 1, 2024
  • NY: $366.30 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $418.91 (physician), effective Jan 1, 2024
  • OK: $587.03 (asc), effective Jan 1, 2026
  • TX: $420.64 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $603.59 (medical), effective Jul 1, 2026
  • VT: $1204.74 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $686.17 (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.