42975 CPT® code: payer coverage and prior authorization16 of 17 payer prior-auth lists that name 42975 require prior authorization or set conditions: Cigna, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Texas.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2022 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2022 | Master Precertification List (For Health Care Providers) |
| Cigna | Sleep | All | prior auth required | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Sleep Management | |
| Cigna | Sleep | All | prior auth required | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 |
42975 appears in 9 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Centene, Cigna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Obstructive Sleep Apnea in Adults (0004) | covered if criteria are met | Oct 6, 2026 | payer document |
| Aetna | Obstructive Sleep Apnea in Children (0752) | covered if criteria are met | Oct 30, 2025 | payer document |
| Aetna | Obstructive Sleep Apnea in Children (0752) | listed, no stance (range 42700-42999) | Oct 30, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Sleep Disorders (L.2.01.415) | listed, no stance | payer document | |
| Blue Cross NC | Sleep Apnea: Diagnosis and Medical Management | listed, no stance | Mar 1, 2026 | 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 | |
| BlueCross BlueShield of South Carolina | Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (CAM 701101) 21685 | Hyoid myotomy and suspension | listed, no stance | Jul 1, 2026 | payer document |
| Centene | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) | covered if criteria are met | Jan 1, 2026 | payer document |
| Cigna | Surgical Treatments for Obstructive Sleep Apnea (0158) | listed, no stance | Jun 15, 2026 | payer document |
Prior authorization required or conditional in VA.
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.