89258 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 89258

15 of 15 payer prior-auth lists that name 89258 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Humana, Molina Healthcare of California, Molina Healthcare of Texas, Neighborhood Health Partnership, Oxford Health Plans, Surest, UnitedHealthcare.

Payer coverage policies that name 89258

89258 appears in 22 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

Recent prior-auth changes

• Mar 1, 2026: PA removed, UnitedHealthcare
• Sep 1, 2025: conditions changed, UnitedHealthcare
• May 1, 2025: conditions changed, UnitedHealthcare
• Dec 1, 2024: conditions changed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in IN.

• ND: $0.00 (physician), effective Aug 1, 2026
• VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
• WY: $356.30 (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.