52250 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 52250

Payer coverage policies that name 52250

52250 appears in 4 coverage policies from Aetna, Anthem, Capital Blue Cross.

PayerPolicyRole in policyReviewedDocument
AetnaBupivacaine Liposome (Exparel) (0941)listed, no stance (range 50010-53899)Jul 30, 2026payer document
AetnaObsolete and Unreliable Tests and Procedures (0438)
Lupus erythematosus (LE) cell test or the LE Cell Phenomenon test - no specific code .		not coveredJul 16, 2026payer document
AnthemOutpatient Cystourethroscopy (CG-SURG-51)covered if criteria are metMay 14, 2026payer document
Capital Blue CrossExperimental and Investigational Procedures (MP 4.002)
Procedure codes: Genitourinary		listed, no stanceSep 1, 2026payer document

Medicaid fee-for-service

  • AZ: $1171.31 (asc), effective Oct 1, 2026
  • CO: $108.51 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $164.69 (physician, non-facility), effective Jan 1, 2026
  • IL: $162.23 (practitioner), effective Apr 1, 2024
  • IN: $183.38 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $350.00 (asc, facility), effective Aug 1, 1982
  • KY: $1681.93 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1170.42 (asc), effective May 1, 2026
  • ND: $991.50 (physician, facility), effective Aug 1, 2026
  • NE: $785.00 (asc), effective Jul 1, 2024
  • NY: $123.90 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $190.11 (physician), effective Jan 1, 2000
  • OK: $1534.46 (asc), effective Jan 1, 2026
  • TX: $1142.90 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $183.45 (medical), effective Jul 1, 2026
  • VT: $2737.01 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1558.88 (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.