43198 CPT® code: payer coverage and prior authorization6 of 6 payer prior-auth lists that name 43198 require prior authorization or set conditions: Humana.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Humana | Endoscopy Services | All | prior auth required | Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services | ||
| Humana | Endoscopy Services | All | prior auth required | Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services | ||
| Humana | Endoscopy Services | All | prior auth required | Humana Prior Authorization List (PAL): Cardiovascular and Endoscopy Services | ||
| Humana | Humana Healthy Horizons | KY | prior auth under conditions | Under 59 | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. |
| Humana | Humana Healthy Horizons | SC | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical | |
| Humana | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management |
43198 appears in 2 coverage policies from Aetna, Centene.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) | covered if criteria are met | Oct 29, 2025 | payer document |
| Aetna | Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) | covered if criteria are met (range 43197-43198) | Oct 29, 2025 | payer document |
| Centene | Anesthesiology Services for Gastrointestinal Endoscopy (CP.MP.161) | covered if criteria are met | May 1, 2019 | payer document |
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.