Payer policies › CPT 5726857268 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 57268 3 of 3 payer prior-auth lists that name 57268 require prior authorization or set conditions: Humana, Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Humana Humana Puerto Rico MA and Dual Medicare-Medicaid PR prior auth required Nov 3, 2025 Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth under conditions site of care: outpatient hospital Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
Payer coverage policies that name 57268 57268 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Acupuncture and Dry Needling (0135) listed, no stance (range 56405-58999) Mar 25, 2026 payer document Aetna Urological Supplies (0533) listed, no stance (range 56405-58999) Jul 30, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Medicaid fee-for-service AZ: $1698.98 (asc), effective Oct 1, 2026 CO: $408.20 (chp_plus, non-facility), effective Jul 1, 2026 FL: $355.11 (physician, non-facility), effective Jan 1, 2026 IL: $532.80 (practitioner), effective Jul 1, 2026 IN: $389.55 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $312.27 (asc, facility), effective Aug 1, 1982 KY: $2240.80 (asc), effective Jan 1, 2026 LA: $217.00 (asc), effective Jul 1, 2012 MA: $1543.91 (asc), effective May 1, 2026 MS: $1780.46 (comprehensive, facility), effective Oct 1, 2025 ND: $1320.95 (physician, facility), effective Aug 1, 2026 NE: $637.00 (asc), effective Jul 1, 2024 NY: $231.51 (physician_surgery, facility), effective Jul 1, 2026 OH: $390.52 (physician), effective Jan 1, 2024 OK: $2044.33 (asc), effective Jan 1, 2026 TX: $1526.99 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $463.58 (medical), effective Jul 1, 2026 VT: $3884.21 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $339.40 (asc), effective Jul 1, 2026 WY: $2212.27 (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.