54865 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 54865

Payer coverage policies that name 54865

54865 appears in 1 coverage policy from Aetna.

Medicaid fee-for-service

• AZ: $1171.31 (asc), effective Oct 1, 2026
• CO: $262.27 (chp_plus, non-facility), effective Jul 1, 2026
• FL: $261.33 (physician, non-facility), effective Jan 1, 2026
• IL: $246.29 (practitioner), effective Apr 1, 2024
• IN: $281.43 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
• KS: $202.09 (asc, facility), effective Jan 1, 2007
• KY: $1681.93 (asc), effective Jan 1, 2026
• LA: $182.30 (asc), effective Jul 1, 2012
• MA: $1170.42 (asc), effective May 1, 2026
• MS: $1324.25 (comprehensive, facility), effective Oct 1, 2025
• ND: $991.50 (physician, facility), effective Aug 1, 2026
• NE: $552.00 (asc), effective Jul 1, 2024
• NY: $179.46 (physician_surgery, facility), effective Jul 1, 2026
• OH: $239.70 (physician), effective Jan 1, 2024
• 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: $291.09 (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.