Payer policies › CPT 5745457454 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 57454 2 of 2 payer prior-auth lists that name 57454 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source 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 57454 57454 appears in 3 coverage policies from Aetna, Regence.
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 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 Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Apr 1, 2026: PA removed, UnitedHealthcare Community Plan Medicaid fee-for-service AZ: $42.43 (asc), effective Oct 1, 2026 CO: $135.02 (chp_plus, non-facility), effective Jul 1, 2026 FL: $92.48 (physician, facility), effective Jan 1, 2026 IL: $92.72 (practitioner), effective Apr 1, 2024 IN: $102.22 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $225.75 (asc, facility), effective Aug 1, 1982 KY: $75.69 (asc), effective Jan 1, 2026 LA: $136.09 (professional), effective Jul 1, 2025 MA: $61.66 (asc), effective May 1, 2026 MS: $60.81 (comprehensive, facility), effective Oct 1, 2025 ND: $74.87 (physician, facility), effective Aug 1, 2026 NE: $171.66 (physician, facility), effective Jul 1, 2026 NY: $70.04 (midwife, facility), effective Jul 1, 2026 OH: $103.03 (physician, facility), effective Jan 1, 2024 OK: $69.05 (asc), effective Jan 1, 2026 TX: $65.06 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $120.73 (medical, facility), effective Jul 1, 2026 VT: $236.61 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $69.18 (physician, facility), effective Jul 1, 2026 WY: $134.76 (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.