69540 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 69540

Payer coverage policies that name 69540

69540 appears in 1 coverage policy from Aetna.

Medicaid fee-for-service

• AZ: $90.00 (asc), effective Oct 1, 2026
• CO: $141.71 (chp_plus, non-facility), effective Jul 1, 2026
• FL: $93.52 (physician, facility), effective Jan 1, 2026
• IL: $87.14 (practitioner), effective Apr 1, 2024
• IN: $99.64 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
• KS: $300.00 (asc, facility), effective Aug 1, 1982
• KY: $160.56 (asc), effective Jan 1, 2026
• LA: $163.79 (professional), effective Jul 1, 2025
• MA: $134.97 (asc), effective May 1, 2026
• MS: $124.47 (comprehensive, facility), effective Oct 1, 2025
• ND: $158.81 (physician, facility), effective Aug 1, 2026
• NE: $76.16 (physician, facility), effective Jul 1, 2026
• NY: $62.54 (physician_surgery, facility), effective Jul 1, 2026
• OH: $66.97 (physician, facility), effective Jan 1, 2024
• OK: $146.48 (asc), effective Jan 1, 2026
• TX: $136.76 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
• VA: $104.17 (medical, facility), effective Jul 1, 2026
• VT: $1204.74 (outpatient_hospital_opps), effective Feb 1, 2026
• WA: $73.00 (physician, facility), effective Jul 1, 2026
• WY: $686.17 (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.