15847 CPT® code: payer coverage and prior authorization111 of 111 payer prior-auth lists that name 15847 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, Humana, Medicare, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth required | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Medicare | Prior Authorization for Certain Hospital OPD Services | All | prior auth required | Jul 1, 2020 | Prior Authorization (PA) Program for Certain Hospital OPD Services Operational Guide, Appendix A | |
| Aetna | Commercial | All | prior auth required | site of care: procedure and site of service review | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 22, 2007 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jan 22, 2007 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 22, 2007 | Master Precertification List (For Health Care Providers) |
| Cigna | Other Services | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| Cigna | Other Services | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Other Services |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Oct 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| 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 | |
| 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 | 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 | KY | prior auth required | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. | |
| 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 | OK | prior auth required | Jan 1, 2027 | Humana Healthy Horizons® in Oklahoma 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 required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Apr 1, 2023 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Prior Authorization required in any setting | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Prior Authorization Required in any setting | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| 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 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 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 |
15847 appears in 58 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Blue Shield of California, Capital Blue Cross, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair (0211) | covered if criteria are met | Aug 18, 2026 | payer document |
| Aetna | Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair (0211) | listed, no stance | Aug 18, 2026 | payer document |
| Aetna | Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair (0211) | not covered | Aug 18, 2026 | payer document |
| Aetna | Cosmetic Surgery and Procedures (0031) Thermal therapy (e.g., radiofrequency (ThermiVa and Viveve procedures) and laser), Laviv (azficel-T) | not covered | Jun 25, 2026 | payer document |
| Aetna | Kidney Transplantation (0493) | not covered | Jul 30, 2026 | payer document |
| Aetna | Lymphedema (0069) | covered if criteria are met | Feb 25, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 10040-19499) | Jul 29, 2026 | payer document |
| Anthem | Panniculectomy and Abdominoplasty (CG-SURG-99) | not covered | Feb 19, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Wide Abdominoplasty Rectus Plication Warp (L.7.01.419) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Gender Affirming Care MEDICAL COVERAGE POLICY | 5 | covered if criteria are met | Apr 1, 2026 | payer document |
| Blue Cross NC | Abdominoplasty and Panniculectomy | listed, no stance | Aug 1, 2026 | payer document |
| Blue Shield of California | Panniculectomy, Abdominoplasty, and Surgical Management BSC7.04 of Diastasis Recti | listed, no stance | payer document | |
| Capital Blue Cross | Cosmetic and Reconstructive Surgery (MP 1.004) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Capital Blue Cross | Cosmetic and Reconstructive Surgery (MP 1.004) Procedure codes | not covered | 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 |
| Centene | Cosmetic and Reconstructive Procedures Reference Number: CP.MP.31 (CP.MP.31) | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Gender Dysphoria Treatment (0266) | not covered | Sep 15, 2026 | payer document |
| Cigna | Lymphedema and Lipedema Surgical Treatments (0531) | not covered | Feb 15, 2026 | payer document |
| Cigna | Panniculectomy and Abdominoplasty (0027) | not covered | Jun 15, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Cosmetic and Reconstructive Procedures (SUR716.001) CPT Codes 11200, 11201, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, | listed, no stance | Jan 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Surgical Treatments for Breast Cancer-Related Lymphedema (SUR701.024) CPT Codes 15756, 15758, 15830, 15832, 15833, 15834, 15835, 15836, 15837, | listed, no stance | Dec 15, 2025 | payer document |
| Premera Blue Cross | Cosmetic and Reconstructive Services Page | 8 of 20 | ∞ | listed, no stance | Apr 1, 2026 | payer document |
| Premera Blue Cross | Gender Transition/Affirmation Surgery and Related Services (7.01.557) Page | 30 of 59 | ∞ | listed, no stance | Jul 1, 2026 | payer document |
| Premera Blue Cross | Panniculectomy and Excision of Redundant Skin (7.01.523) Page | 4 of 12 | ∞ | listed, no stance | Jun 19, 2026 | payer document |
| Regence | Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Cosmetic and Reconstructive Procedures (MMP022.16) Abdominal Lipectomy/Panniculectomy | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (2026T0580U) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (CS145.T) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Gender Dysphoria Treatment (for Indiana Only) (CS145IN.11) | listed, no stance | May 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 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 |
| UnitedHealthcare | Panniculectomy Surgery (CS093.Y) The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (MP.014.28) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Idaho Only) (CS093ID.E) The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Kansas Only) (CS093KS.03) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Kentucky Only) (CS093KY.12) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Nebraska Only) (CS093NE.V) The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for New Jersey Only) (CS093NJ.W) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for New Mexico Only) (CS093NM.D) The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for North Carolina Only) (CSNC.MP.014.08) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Ohio Only) (CS093OH.D) The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Pennsylvania Only) (CS093PA.Y) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Panniculectomy Surgery (for Tennessee Only) (CS093TN.X) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (2026T0636H) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (CS355.F) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Idaho Only) (CS355ID.C) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Indiana Only) (CS355IN.05) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Kansas Only) (CS355KS.03) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Kentucky Only) (CS355KY.05) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Nebraska Only) (CS355NE.F) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for New Jersey Only) (CS355NJ.E) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for New Mexico Only) (CS355NM.D) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for North Carolina Only) (CSNCT0355.05) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Ohio Only) (CS355OH.D) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Pennsylvania Only) (CS355PA.E) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Surgery for the Prevention and Treatment of Lymphedema (for Tennessee Only) (CS355TN.E) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Surgical Procedures (MMP108.10) Lymphedema Surgical Treatments | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in CO, FL, IN, LA, NE, NY, VA, VT, WY.
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.