Payer policies › CPT 1205212052 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 12052 2 of 2 payer prior-auth lists that name 12052 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth under conditions site of care: outpatient hospital Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
Payer coverage policies that name 12052 12052 appears in 3 coverage policies from Aetna, Anthem.
Payer Policy Role in policy Reviewed Document Aetna Bone and Tendon Graft Substitutes and Adjuncts (0411) listed, no stance (range 12031-12057) Aug 18, 2026 payer document Aetna Skin and Soft Tissue Substitutes (0244) not covered (range 10040-19499) Jul 29, 2026 payer document Anthem Treatment of Keloids and Scar Revision (CG-SURG-31) covered if criteria are met (range 12031-13153) May 14, 2026 payer document
Recent prior-auth changes Oct 1, 2026: PA removed, UnitedHealthcare Community Plan Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, Oxford Health Plans Oct 1, 2026: PA removed, UnitedHealthcare Oct 1, 2026: PA removed, UnitedHealthcare Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Jun 1, 2026: conditions changed, UnitedHealthcare Medicaid fee-for-service AZ: $113.87 (asc), effective Oct 1, 2026 CO: $192.83 (chp_plus, non-facility), effective Jul 1, 2026 FL: $300.42 (pediatric_surgery, pediatric surgeon), effective Jan 1, 2025 IL: $134.35 (practitioner), effective Apr 1, 2024 IN: $154.56 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $300.00 (asc, facility), effective Aug 1, 1982 KY: $203.16 (asc), effective Jan 1, 2026 LA: $247.22 (professional), effective Jul 1, 2025 MA: $137.23 (asc), effective May 1, 2026 MS: $160.44 (comprehensive, facility), effective Oct 1, 2025 ND: $200.94 (physician, facility), effective Aug 1, 2026 NE: $128.39 (physician, facility), effective Jul 1, 2026 NY: $161.60 (physician_surgery, facility), effective Jul 1, 2026 OH: $100.53 (physician, facility), effective Jan 1, 2024 OK: $185.34 (asc), effective Jan 1, 2026 TX: $143.08 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $149.59 (medical, facility), effective Jul 1, 2026 VT: $315.64 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $102.62 (physician, facility), effective Jul 1, 2026 WY: $179.77 (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.