94002 Insurance Policy Changes

CPT 94002, in plain terms, covers Initiation and management of pressure or volume preset ventilation for a hospital inpatient or observation patient, initial day. CPT 94002 is referenced in 5 tracked payer policy changes from Arizona Medicaid - AHCCCS, Aetna, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 94002 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 94002 on AAPC

Arizona Medicaid - AHCCCS · Effective Aug 24, 2026High impact
AHCCCS DFSM Claims Clues - August 2026
Already effective August 24, 2026, AHCCCS prepayment reviews claims for H2038 (skills training and development, per diem) billed without a group modifier, and supporting medical documentation must be submitted with the initial claim and every replacement claim. Already effective September 4, 2026, the Alivia analytics tool reviews NEMT trip tickets and a set of claim edits, and claims containing the listed errors will be denied. Already effective September 1, 2026, claims submitted by fee-for-service providers that include a referring, ordering, attending or prescribing provider who is not registered with AHCCCS will be denied.
Aetna · Identified Aug 18, 2026Medium impact
Nitric Oxide, Inhalational (INO) (CPB 0518, reviewed 2026-07-02)
Aetna considers inhaled nitric oxide (INO) therapy medically necessary as a component of the treatment of hypoxic respiratory failure in neonates 34 weeks gestation or greater when criteria are met, for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease, and as a method of assessing pulmonary vaso-reactivity in persons with pulmonary hypertension. Aetna considers INO therapy experimental, investigational, or unproven for all other indications, including acute bronchiolitis, acute respiratory distress syndrome, sickle cell disease vaso-occlusive crises, COVID-19 related pneumonia, and traumatic brain injury. The policy lists no specific CPT code for INO therapy.
Aetna · Identified Aug 13, 2026Medium impact
Positive Pressure Ventilation (CPB 0452, reviewed 2026-07-01)
Aetna covers bilevel positive airway pressure (bilevel PAP) devices as durable medical equipment for members with restrictive thoracic disorders, severe COPD, central sleep apnea, complex sleep apnea, hypoventilation syndrome, or obstructive sleep apnea, when the medical necessity criteria for each condition are met. A bilevel PAP device with a backup rate feature is covered for these conditions only under specific criteria, and a backup rate feature has no proven value for obstructive sleep apnea. Ventilators with noninvasive interfaces are covered for severe neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure from COPD where interruption or failure of respiratory support would lead to death, and noninvasive positive pressure ventilation is experimental, investigational, or unproven for asthma, pneumonia, bronchiolitis, acute lung injury and other indications not listed as covered.
Blue Cross Blue Shield of Rhode Island · Identified Jun 20, 2026Medium impact
June 2017
Effective August 1, 2017, BCBSRI moves professional drug reimbursement from the Average Wholesale Price model to the Average Sales Price model, paying drugs for Commercial members at 115% of ASP on August 1, 2017, 110% of ASP on April 1, 2018 and 106% of ASP on April 1, 2019, and drugs for Medicare Advantage members at 106% of ASP on August 1, 2017. Provider-purchased vaccines remain at 95% of AWP, and drugs without a published CMS ASP continue to be paid at 90% of AWP. Effective June 1, 2017, percutaneous electrical nerve stimulation and percutaneous neuromodulation therapy for chronic pain are considered not medically necessary for BlueCHiP for Medicare and Commercial products.
BCBS Arizona · Identified Jun 16, 2026Medium impact
Telehealth Services
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.

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REFERENCE DATA

Payers with rules2

Payers requiring prior auth2

CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements
Community Health Plan of Imperial Valley · Effective December 31, 2025
Prior authorization required
Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 94002?

CalViva Health lists 94002 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 94002?

Community Health Plan of Imperial Valley lists 94002 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 94002?

There are 5 tracked policy changes affecting CPT 94002, including updates from Arizona Medicaid - AHCCCS, Aetna, Blue Cross Blue Shield of Rhode Island. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 94002?

Payers that have issued tracked updates for CPT 94002 include: Arizona Medicaid - AHCCCS, Aetna, Blue Cross Blue Shield of Rhode Island, BCBS Arizona.

How do I get notified when CPT 94002 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 94002. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 94002?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 94002 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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AHCCCS DFSM Claims Clues - August 2026

Nitric Oxide, Inhalational (INO) (CPB 0518, reviewed 2026-07-02)

Positive Pressure Ventilation (CPB 0452, reviewed 2026-07-01)

June 2017

Telehealth Services

Prior authorization required