11922 CPT® code: payer coverage and prior authorization12 of 12 payer prior-auth lists that name 11922 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of New Mexico, Blue Shield of California, Humana, Oxford Health Plans, Rocky Mountain Health Plans, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | Only gender dysphoria dx, members in treatment as of 1/1/26 | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Oct 1, 2026 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 | |
| Humana | Humana Healthy Horizons | LA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate | |
| Humana | Humana Healthy Horizons | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 | |
| UnitedHealthcare Community Plan | Indiana Hoosier Care Connect | IN | prior auth required | Oct 1, 2026 | Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Indiana PathWays for Aging (MLTSS) | IN | prior auth required | Oct 1, 2026 | Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) and OneCare | MA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026 |
11922 appears in 38 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, BlueCross BlueShield of South Carolina, Capital Blue Cross, Centene, Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Breast Reconstructive Surgery (0185) | covered if criteria are met | Apr 22, 2026 | payer document |
| Aetna | Cosmetic Surgery and Procedures (0031) | covered if criteria are met (range 11920-11922) | Jun 25, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 10040-19499) | Jul 29, 2026 | payer document |
| Aetna | Vitiligo (0422) | not covered (range 11920-11922) | Jul 16, 2026 | payer document |
| Anthem | Cosmetic and Reconstructive Services: Skin Related (ANC.00007) | covered if criteria are met (range 11920-11922) | Nov 6, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Tattooing (L.7.01.422) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Gender Affirming Care MEDICAL COVERAGE POLICY | 4 | covered if criteria are met | Apr 1, 2026 | payer document |
| Blue Cross Blue Shield of Massachusetts | Reconstructive Breast Surgery (428) | listed, no stance | payer document | |
| Blue Cross NC | Breast Surgeries | listed, no stance | Aug 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Breast Surgical Procedures/Prosthesis (CAM 079) | listed, no stance | Sep 1, 2026 | payer document |
| Capital Blue Cross | Gender Affirming Surgery (MP 1.144) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| Capital Blue Cross | Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras (MP 1.103) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| Centene | Cosmetic and Reconstructive Procedures Reference Number: CP.MP.31 (CP.MP.31) | covered if criteria are met | Aug 1, 2026 | payer document |
| Premera Blue Cross | Cosmetic and Reconstructive Services | listed, no stance | Apr 1, 2026 | payer document |
| Premera Blue Cross | Gender Transition/Affirmation Surgery and Related Services (7.01.557) | listed, no stance | Jul 1, 2026 | payer document |
| Premera Blue Cross | Reconstructive Breast Surgery/Management of Breast Implants | listed, no stance | Aug 24, 2026 | payer document |
| Regence | Cosmetic and Reconstructive Procedures (Surgery 12) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (CS011.W) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (MP.003.29) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Idaho Only) (CS011ID.C) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Indiana Only) (CS011IN.10) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Kansas Only) (CS011KS.02) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Kentucky Only) (CS011KY.13) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Nebraska Only) (CS011NE.V) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for New Mexico Only) (CS011NM.C) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Ohio Only) (CS011OH.C) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Pennsylvania Only) (CS011PA.W) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Tennessee Only) (CS011TN.T) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (CS027.AD) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (MP.007.33) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Idaho Only) (CS027ID.C) The following codes may be Cosmetic; review is required to determine if considered Cosmetic or | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Kansas Only) (CS027KS.03) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Kentucky Only) (CS027KY.13) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Nebraska Only) (CS027NE.U) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for New Mexico Only) (CS027NM.E) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Ohio Only) (CS027OH.E) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Pennsylvania Only) (CS027PA.AD) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (for Tennessee Only) (CS027TN.AB) | listed, no stance | Aug 1, 2026 | payer document |
Prior authorization required or conditional in IN, NE.
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.