69420 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 69420

Payer coverage policies that name 69420

69420 appears in 2 coverage policies from Aetna, Anthem.

PayerPolicyRole in policyReviewedDocument
AetnaMyringotomy and Tympanostomy Tube (0418)covered if criteria are metJun 30, 2026payer document
AetnaMyringotomy and Tympanostomy Tube (0418)listed, no stance (range 69420-69799)Jun 30, 2026payer document
AnthemMyringotomy and Tympanostomy Tube Insertion (CG-SURG-46)covered if criteria are metFeb 19, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in WV.

  • AZ: $72.67 (asc), effective Oct 1, 2026
  • CO: $147.83 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $85.98 (physician, facility), effective Jan 1, 2026
  • IL: $81.45 (practitioner), effective Apr 1, 2024
  • IN: $93.59 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $267.00 (asc, facility), effective Aug 1, 1982
  • KY: $126.41 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $87.46 (asc), effective May 1, 2026
  • MS: $99.30 (comprehensive, facility), effective Oct 1, 2025
  • ND: $74.52 (physician, facility), effective Aug 1, 2026
  • NE: $71.79 (physician, facility), effective Jul 1, 2026
  • NY: $57.81 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $61.43 (physician, facility), effective Jan 1, 2024
  • OK: $115.33 (asc), effective Jan 1, 2026
  • TX: $87.58 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $95.78 (medical, facility), effective Jul 1, 2026
  • VT: $183.90 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $66.50 (physician, facility), effective Jul 1, 2026
  • WY: $104.75 (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.