HCPCS Level II › A codes A4266 DiaphragmDiaphragm for contraceptive use
Medicare coverage: Not payable by Medicare Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for A4266 Physician Fee Schedule (CY 2026, RVU26D) Status I: not valid for Medicare (Medicare uses another code).
Payer policies and prior authorization for A4266 Payer coverage policies that name A4266 A4266 appears in 1 coverage policy from Premera Blue Cross.
Payer Policy Role in policy Reviewed Document Premera Blue Cross Preventive CareContraceptive implantable devices (insertion and removal) covered if criteria are met Sep 21, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in OH.
CO: $33.96 (health_first_colorado), effective Jul 1, 2026 KS: $18.00 (default, Exempt Physician), effective Jan 1, 2003 KY: $22.00 (preventive), effective Jan 1, 2026 LA: $53.27 (take_charge_plus), effective Jul 1, 2014 ND: $0.00 (dme), effective Aug 1, 2026 NY: $37.45 (dme), effective Jul 1, 2026 OH: $25.46 (dme), effective Apr 1, 2003 OK: $16.01 (dme), effective Aug 1, 2020 TX: $23.25 (certified_nurse_midwife_cnm, Certified Nurse Midwife (Cnm), facility), effective Apr 1, 2026 VA: $41.35 (medical), effective Feb 1, 2009 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $74.90 (family_planning, 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.