`43242` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 43242

32 of 32 payer prior-auth lists that name 43242 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Humana, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth under conditions	place of service 19, 21, 22; site of care: hospital (not ASC)	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
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	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 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	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois 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	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	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	site of care: outpatient hospital	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth under conditions	site of care: outpatient hospital	Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth under conditions	site of care: outpatient hospital	Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth under conditions	site of care: outpatient hospital, ASC	Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	site of care: outpatient hospital	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth under conditions	site of care: outpatient hospital	Jul 1, 2020	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth under conditions	site of care: outpatient hospital	Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023

Payer coverage policies that name 43242

43242 appears in 5 coverage policies from Aetna, Centene, Premera Blue Cross.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Endoscopic Ultrasonography (0446)	covered if criteria are met	Jul 22, 2026	payer document
Aetna	Risankizumab-rzaa (Skyrizi) (1009)	listed, no stance (range 43233-43259)	Jul 1, 2026	payer document
Aetna	Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738)	covered if criteria are met (range 43233-43270)	Oct 29, 2025	payer document
Aetna	Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738)	covered if criteria are met	Oct 29, 2025	payer document
Centene	Anesthesiology Services for Gastrointestinal Endoscopy (CP.MP.161)	covered if criteria are met	May 1, 2019	payer document
Premera Blue Cross	Upper Gastrointestinal (UGI) Endoscopy in Adults (2.01.533)	listed, no stance	Jul 14, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2025: conditions changed, UnitedHealthcare Community Plan
Mar 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

AZ: $617.94 (asc), effective Oct 1, 2026
CO: $205.73 (chp_plus, non-facility), effective Jul 1, 2026
FL: $178.72 (physician, non-facility), effective Jan 1, 2026
IL: $201.55 (practitioner), effective Jul 1, 2026
IN: $200.00 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $225.00 (asc, facility), effective Jan 1, 2001
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: $201.92 (physician_surgery, facility), effective Jul 1, 2026
OH: $224.25 (physician), effective Jul 1, 2008
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: $199.07 (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.

43242 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 43242

Payer coverage policies that name 43242

Recent prior-auth changes

Medicaid fee-for-service

`43242` CPT® code: payer coverage and prior authorization