15738 CPT® code: payer coverage and prior authorization31 of 31 payer prior-auth lists that name 15738 require prior authorization or set conditions: Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | 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 Neighborhood Health Partnership Effective September 1, 2026 |
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.8901 | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.8901 | 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 under conditions | only with dx F64.A, F64.0, F64.1, F64.2, F64.8, F64.9 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | 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 Complete Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, F64.A | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.8901 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.8901 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.8901 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley 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 | 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 OneCare | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Nov 1, 2025 | CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025 |
| 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 | |
| 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 | New Jersey FamilyCare | NJ | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 | North Carolina Medicaid | NC | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024 |
| UnitedHealthcare Community Plan | Ohio Medicaid | OH | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 under conditions | Prior authorization is only required for these codes with these DX codes. | Jan 1, 2017 | 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 | Wisconsin BadgerCare Plus and Medicaid SSI | WI | 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 Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community |
15738 appears in 27 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Capital Blue Cross, Cigna, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Gender Affirming Surgery (0615) | covered if criteria are met | Sep 8, 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 Rhode Island | Gender Affirming Care MEDICAL COVERAGE POLICY | 4 | covered if criteria are met | Apr 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 |
| Cigna | Gender Dysphoria Treatment (0266) | covered if criteria are met | Sep 15, 2026 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (MMP022.16) Myocutaneous Flaps for Trunk, and Extremities | listed, no stance | Sep 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 (CS027.AD) | listed, no stance | Jul 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 Jersey Only) (CS027NJ.W) | 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 North Carolina Only) (CSNC.MP.007.10) | 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 |
| UnitedHealthcare | Gender Dysphoria Treatment (CS145.T) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (2026T0580U) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for Kansas Only) (CS145KS.02) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for New Jersey Only) (CS145NJ.L) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for New Mexico Only) (CS145NM.D) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for North Carolina Only) (CSNCT0145.04) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for Ohio Only) (CS145OH.C) | listed, no stance | Sep 1, 2024 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for Pennsylvania Only) (CS145PA.P) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria and Gender Reassignment Surgery (MMP365.14) Other Ancillary Services | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in CO, WA.
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.