Payer policies › CPT 4325343253 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 43253 15 of 15 payer prior-auth lists that name 43253 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana.
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) 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
Payer coverage policies that name 43253 43253 appears in 9 coverage policies from Aetna, Centene, Regence.
Payer Policy Role in policy Reviewed Document Aetna Botulinum Toxin (0113) covered if criteria are met Jul 14, 2026 payer document Aetna Dysphagia Therapy (0625) covered if criteria are met Sep 25, 2025 payer document Aetna Endoscopic Ultrasonography (0446) covered if criteria are met Jul 22, 2026 payer document Aetna Obesity Surgery (0157) covered if criteria are met Jul 21, 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 Aetna Vocal Cord Paralysis / Insufficiency Treatments (0253) covered if criteria are met Apr 15, 2026 payer document Centene Anesthesiology Services for Gastrointestinal Endoscopy (CP.MP.161) covered if criteria are met May 1, 2019 payer document Regence Surgical Site of Care – Hospital Outpatient (Utilization Management 19) listed, no stance May 1, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Medicaid fee-for-service AZ: $617.94 (asc), effective Oct 1, 2026 CO: $205.45 (chp_plus, non-facility), effective Jul 1, 2026 FL: $178.98 (physician, non-facility), effective Jan 1, 2026 IL: $177.04 (practitioner), effective Apr 1, 2024 IN: $200.13 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $345.10 (asc, facility), effective Jan 1, 2014 KY: $873.00 (asc), effective Jan 1, 2026 LA: $231.58 (professional), effective Jan 1, 2014 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: $318.62 (physician, non-facility), effective Jul 1, 2026 NY: $148.92 (physician_surgery, facility), effective Jul 1, 2026 OH: $209.61 (physician), effective Jan 1, 2014 OK: $206.03 (physician, non-facility), effective Jul 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: $199.36 (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.