Payer policies › CPT 9200492004 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 92004 Payer coverage policies that name 92004 92004 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island.
Payer Policy Role in policy Reviewed Document Aetna Cataract Surgery (0508)Femtosecond laser-assisted cataract surgery, capsular tension rings (e.g., StabilEyes) covered if criteria are met (range 92002-92004) Oct 9, 2026 payer document Aetna Eye Prosthesis (0619) covered if criteria are met (range 92002-92014) Sep 24, 2026 payer document Blue Cross & Blue Shield of Mississippi Corneal Topographycomputerassisted Corneal Topographyphotokeratoscopy (L.9.03.408) listed, no stance (range 92002-92014) payer document Blue Cross & Blue Shield of Rhode Island Ophthalmology Examination and Routine Eye Exam covered if criteria are met Mar 6, 2024 payer document
Medicaid fee-for-service AZ: $56.48 (outpatient_hospital, RF133), effective Oct 1, 2025 CO: $122.96 (chp_plus, non-facility), effective Jul 1, 2026 FL: $63.42 (physician, facility), effective Jan 1, 2026 IL: $62.11 (practitioner), effective Apr 1, 2024 IN: $73.39 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $84.58 (default, Exempt Physician), effective Aug 1, 2024 KY: $94.51 (physician, facility), effective Jan 1, 2026 LA: $117.44 (professional), effective Jul 1, 2025 MA: $69.74 (physician_medicine, facility), effective May 1, 2024 MS: $124.27 (comprehensive), effective Jul 1, 2020 MT: $89.20 (optometric, facility), effective Jul 1, 2025 ND: $167.47 (physician), effective Aug 1, 2026 NE: $56.69 (physician, facility), effective Jul 1, 2026 NY: $30.30 (ordered_ambulatory), effective Jul 24, 2026 OH: $36.54 (physician, facility), effective Jan 1, 2024 OK: $71.02 (physician, facility), effective Jul 1, 2026 TX: $75.92 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, facility), effective Apr 1, 2016 VA: $67.42 (medical, facility), effective Jul 1, 2026 VT: $103.38 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $46.06 (physician, facility), effective Jul 1, 2026 WY: $58.88 (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.