69005 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 69005

1 of 1 payer prior-auth lists that name 69005 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)

Medicaid fee-for-service

  • AZ: $77.69 (asc), effective Oct 1, 2026
  • CO: $148.90 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $113.78 (physician, facility), effective Jan 1, 2026
  • IL: $110.12 (practitioner), effective Apr 1, 2024
  • IN: $124.88 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $300.00 (asc, facility), effective Aug 1, 1982
  • KY: $138.60 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $113.81 (asc), effective May 1, 2026
  • MS: $105.58 (comprehensive, facility), effective Oct 1, 2025
  • ND: $137.09 (physician, facility), effective Aug 1, 2026
  • NE: $240.24 (physician, facility), effective Jul 1, 2026
  • NY: $75.72 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $82.02 (physician, facility), effective Jan 1, 2024
  • OK: $128.18 (physician, facility), effective Jul 1, 2026
  • TX: $113.23 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $126.74 (medical, facility), effective Jul 1, 2026
  • VT: $1282.40 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $87.14 (physician, facility), effective Jul 1, 2026
  • WY: $730.40 (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.