Payer policies › CPT 9101391013 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 91013 Payer coverage policies that name 91013 91013 appears in 1 coverage policy from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Gastrointestinal Manometry (0616) covered if criteria are met Sep 3, 2026 payer document
Medicaid fee-for-service AZ: $291.80 (outpatient_hospital), effective Oct 1, 2013 CO: $11.20 (chp_plus, non-facility), effective Jul 1, 2026 FL: $13.88 (physician), effective Jan 1, 2026 IL: $16.36 (practitioner), effective Apr 1, 2024 IN: $12.17 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $7.09 (default, Exempt Physician), effective Aug 1, 2024 KY: $20.18 (physician, facility), effective Jan 1, 2026 LA: $4.68 (professional), effective Feb 1, 2013 MA: $20.14 (physician_medicine), effective May 1, 2024 MS: $22.72 (comprehensive), effective Jul 1, 2026 ND: $10.51 (physician), effective Aug 1, 2026 NE: $25.22 (physician, non-facility), effective Jul 1, 2026 NY: $7.38 (ordered_ambulatory), effective Jul 24, 2026 OH: $13.50 (physician), effective Jan 1, 2024 OK: $8.66 (physician, non-facility), effective Jul 1, 2026 TX: $21.05 (miscellaneous_other_professionals_portable_x_ray_radiologica, Miscellaneous Other Professionals - Portable X-Ray, Radiological Lab, Physiological Lab, non-facility), effective Sep 1, 2025 VA: $8.39 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $17.58 (physician, facility), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), 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.