49250 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 49250

Payer coverage policies that name 49250

49250 appears in 2 coverage policies from Aetna, Regence.

PayerPolicyRole in policyReviewedDocument
AetnaCosmetic Surgery and Procedures (0031)covered if criteria are metJun 25, 2026payer document
RegenceCosmetic and Reconstructive Procedures (Surgery 12)listed, no stanceJul 1, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in CO, WV.

  • AZ: $1221.04 (asc), effective Oct 1, 2026
  • CO: $471.97 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $441.87 (physician, non-facility), effective Jan 1, 2026
  • IL: $416.07 (practitioner), effective Apr 1, 2024
  • IN: $454.04 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $435.00 (asc, facility), effective Aug 1, 1982
  • KY: $1702.62 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1170.63 (asc), effective May 1, 2026
  • MS: $1348.14 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1003.70 (physician, facility), effective Aug 1, 2026
  • NE: $785.00 (asc), effective Jul 1, 2024
  • NY: $262.79 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $372.56 (physician), effective Jan 1, 2024
  • OK: $1553.34 (asc), effective Jan 1, 2026
  • TX: $1151.54 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $492.19 (medical), effective Jul 1, 2026
  • VT: $2780.04 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1583.39 (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.