Payer policies › CPT 5750557505 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 57505 2 of 2 payer prior-auth lists that name 57505 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 57505 57505 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 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: $56.75 (asc), effective Oct 1, 2026 CO: $122.55 (chp_plus, non-facility), effective Jul 1, 2026 FL: $77.41 (physician, facility), effective Jan 1, 2026 IL: $73.95 (practitioner), effective Apr 1, 2024 IN: $83.80 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $250.00 (asc, facility), effective Aug 1, 1982 KY: $101.25 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $71.17 (asc), effective May 1, 2026 MS: $82.81 (comprehensive, facility), effective Oct 1, 2025 ND: $100.15 (physician, facility), effective Aug 1, 2026 NE: $85.16 (physician, facility), effective Jul 1, 2026 NY: $60.60 (physician_surgery, facility), effective Jul 1, 2026 OH: $56.58 (physician, facility), effective Jan 1, 2024 OK: $92.37 (asc), effective Jan 1, 2026 TX: $91.91 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $101.06 (medical, facility), effective Jul 1, 2026 VT: $715.16 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $59.81 (physician, facility), effective Jul 1, 2026 WY: $407.32 (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.