Payer policies › CPT 9104091040 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 91040 Payer coverage policies that name 91040 91040 appears in 1 coverage policy from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (0738) not covered Oct 29, 2025 payer document
Medicaid fee-for-service AZ: $113.16 (asc), effective Oct 1, 2026 CO: $418.31 (chp_plus, non-facility), effective Jul 1, 2026 FL: $25.48 (physician), effective Jan 1, 2026 IL: $326.62 (practitioner), effective Apr 1, 2024 IN: $376.42 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KY: $315.88 (physician, facility), effective Jan 1, 2026 LA: $94.18 (professional), effective Feb 1, 2013 MA: $420.41 (physician_medicine), effective May 1, 2024 MS: $451.18 (comprehensive), effective Jul 1, 2026 ND: $117.92 (physician, facility), effective Aug 1, 2026 NE: $510.01 (physician, non-facility), effective Jul 1, 2026 NY: $501.12 (ordered_ambulatory), effective Jul 24, 2026 OH: $283.95 (physician), effective Jan 1, 2024 OK: $45.93 (physician, non-facility), effective Jul 1, 2026 TX: $357.12 (miscellaneous_other_professionals_portable_x_ray_radiologica, Miscellaneous Other Professionals - Portable X-Ray, Radiological Lab, Physiological Lab, non-facility), effective Sep 1, 2025 VA: $499.71 (medical), effective Jul 1, 2026 VT: $289.74 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $30.58 (physician, facility), effective Jul 1, 2026 WY: $165.02 (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.