`11971` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 11971

65 of 65 payer prior-auth lists that name 11971 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, Blue Shield of California, CarePlus Health Plans, Humana, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
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 Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
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	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth under conditions	Excludes breast reconstruction following medically necessary mastectomies for b		Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required		Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME 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
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth required		Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare West commercial plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more)	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	Dx group: Breast Reconstructio; Prior authorization is not required for these codes with Breast Reconstruction DX codes.	Oct 1, 2022	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth under conditions	Dx group: Breast Reconstruc; Prior authorization is not required for these codes with	Oct 1, 2022	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	Dx group: Breast; Prior authorization is not required for these codes with Breast Reconstruction DX codes.	Oct 1, 2022	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth under conditions	Dx group: Breast Reconstruct; Prior authorization is not required	Oct 1, 2022	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	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 Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	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 the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth under conditions	PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more)	Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 11971

11971 appears in 25 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Capital Blue Cross, Cigna, 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	Pectus Excavatum and Poland's Syndrome: Surgical Correction (0272)	covered if criteria are met	Apr 17, 2026	payer document
Aetna	Skin and Soft Tissue Substitutes (0244)	not covered (range 10040-19499)	Jul 29, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Breast Reconstruction Following Mastectomy (L.7.01.424)	covered if criteria are met		payer document
Blue Cross Blue Shield of Massachusetts	Reconstructive Breast Surgery (428)	listed, no stance		payer document
Blue Shield of California	BSC7.02 \| Gender Affirmation Surgery	listed, no stance		payer document
Capital Blue Cross	Gender Affirming Surgery (MP 1.144) Procedure codes	covered if criteria are met	Apr 1, 2026	payer document
Cigna	Gender Dysphoria Treatment (0266)	covered if criteria are met	Sep 15, 2026	payer document
Premera Blue Cross	Cosmetic and Reconstructive Services Page \| 7 of 20 \| ∞	listed, no stance	Apr 1, 2026	payer document
Premera Blue Cross	Reconstructive Breast Surgery/Management of Breast Implants Page \| 7 of 27 \| ∞	listed, no stance	Aug 24, 2026	payer document
Regence	Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES	listed, no stance	Nov 1, 2025	payer document
Regence	Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (Surgery 40) NOTE	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Breast Reconstruction (MP.003.29)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Breast Reconstruction (CS011.W)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Breast Reconstruction (for Idaho Only) (CS011ID.C)	listed, no stance	May 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 Jersey Only) (CS011NJ.T)	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 North Carolina Only) (CSNC.MP.003.07)	listed, no stance	Jan 1, 2026	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 (MMP022.16) Removal of Tissue Expander Without Insertion of Implant	listed, no stance	Sep 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Apr 1, 2026: conditions changed, UnitedHealthcare
Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, LA, NE, VT, WV.

AZ: $751.83 (asc), effective Oct 1, 2026
CO: $444.23 (chp_plus, non-facility), effective Jul 1, 2026
FL: $272.13 (physician, facility), effective Jan 1, 2026
IL: $377.02 (practitioner), effective Apr 1, 2024
IN: $426.95 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $202.09 (asc, facility), effective Jan 1, 2007
KY: $1218.59 (asc), effective Jan 1, 2026
LA: $182.30 (asc), effective Jul 1, 2012
MA: $845.19 (asc), effective May 1, 2026
MS: $961.52 (comprehensive, facility), effective Oct 1, 2025
ND: $718.36 (physician, facility), effective Aug 1, 2026
NE: $552.00 (asc), effective Jul 1, 2024
NY: $142.24 (physician_surgery, facility), effective Jul 1, 2026
OH: $281.00 (physician), effective Jan 1, 2024
OK: $1111.74 (asc), effective Jan 1, 2026
TX: $815.20 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $446.76 (medical, facility), effective Jul 1, 2026
VT: $2255.40 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $339.40 (asc), effective Jul 1, 2026
WY: $1284.57 (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.

11971 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 11971

Payer coverage policies that name 11971

Recent prior-auth changes

Medicaid fee-for-service

`11971` CPT® code: payer coverage and prior authorization