43204 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 43204

Payer coverage policies that name 43204

43204 appears in 4 coverage policies from Aetna, Centene.

PayerPolicyRole in policyReviewedDocument
AetnaProlotherapy and Sclerotherapy (0207)covered if criteria are metMar 27, 2026payer document
AetnaSomatostatin Analogs (0693)listed, no stanceJul 15, 2026payer document
AetnaUpper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738)covered if criteria are met (range 43200-43232)Oct 29, 2025payer document
CenteneAnesthesiology Services for Gastrointestinal Endoscopy (CP.MP.161)covered if criteria are metMay 1, 2019payer document

Medicaid fee-for-service

  • AZ: $617.94 (asc), effective Oct 1, 2026
  • CO: $109.52 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $93.78 (physician, non-facility), effective Jan 1, 2026
  • IL: $130.01 (practitioner), effective Apr 1, 2024
  • IN: $103.54 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $225.00 (asc, facility), effective Aug 1, 1982
  • KY: $873.00 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $563.60 (asc), effective May 1, 2026
  • MS: $691.32 (comprehensive, facility), effective Oct 1, 2025
  • ND: $514.64 (physician, facility), effective Aug 1, 2026
  • NE: $413.00 (asc), effective Jul 1, 2024
  • NY: $106.69 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $133.19 (physician), effective Dec 31, 2014
  • OK: $796.46 (asc), effective Jan 1, 2026
  • TX: $564.97 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $104.46 (medical), effective Jul 1, 2026
  • VT: $1489.96 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $308.28 (asc), effective Jul 1, 2026
  • WY: $848.61 (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.