15876 CPT® code: payer coverage and prior authorization43 of 44 payer prior-auth lists that name 15876 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 Shield of California, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, 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, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, 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) | 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 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 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 Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Commercial | All | prior auth required | site of care: procedure and site of service review | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Other Services | All | prior auth required | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Other Services | |
| Cigna | Other Services | All | prior auth required | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| 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 | |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2026 | 2026 Q4 Prior Authorization List | |
| 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 | |
| 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 California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| 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 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 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 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 | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| 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 | |
| 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 | |
| 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 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 |
| 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 | 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 | Virginia Cardinal Care LTSS | VA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 |
15876 appears in 58 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, 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 | 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 | Gender Affirming Surgery (0615) | not covered (range 15876-15879) | Sep 8, 2026 | payer document |
| Aetna | Knee Arthroscopy / Osteoarthritis of the Knee (0673) Balneotherapy, Advanced Arthritis Relief Protocol, high-intensity laser therapy, pulsed vibration therapy, xeno-matrix-induced chondrogenesis - | not covered (range 15876-15879) | Feb 19, 2026 | payer document |
| Aetna | Lymphedema (0069) | covered if criteria are met (range 15876-15879) | Feb 25, 2026 | payer document |
| Aetna | Obesity Surgery (0157) Sleeve gastrectomy with SIPS, Laparoscopic single-anastomosis duodeno-ileal bypass with gastric plication | not covered (range 15876-15879) | Jul 21, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 10040-19499) | Jul 29, 2026 | payer document |
| Anthem | Cosmetic and Reconstructive Services of the Head and Neck (ANC.00008) | covered if criteria are met | Aug 13, 2026 | payer document |
| Anthem | Surgical Treatment of Hyperhidrosis (CG-SURG-116) | not covered (range 15876-15879) | Nov 6, 2025 | payer document |
| Blue Cross & Blue Shield of Mississippi | Surgical Treatments For Lymphedema And Lipedema (L.7.01.440) | not covered | 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 Blue Shield of Massachusetts | Gender Affirming Services (Transgender Services) (189) | covered if criteria are met | payer document | |
| Blue Cross NC | Sex Trait Modification Procedures For Gender Affirming Care | listed, no stance | Apr 1, 2026 | payer document |
| Blue Shield of California | BSC7.02 | Gender Affirmation Surgery | listed, no stance | payer document | |
| Blue Shield of California | BSC7.08 | Cosmetic and Reconstructive Procedures | 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 | 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 |
| Centene | Gender-Affirming Procedures (CP.MP.95) | covered if criteria are met | Jul 1, 2026 | payer document |
| Cigna | Gender Dysphoria Treatment (0266) | not covered | Sep 15, 2026 | payer document |
| Cigna | Redundant Skin Surgery (0470) | not covered | Sep 15, 2026 | payer document |
| Cigna | Scar Revision (0328) | 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) | Gender Assignment Surgery and Gender Reassignment Surgery with Related Services (SUR717.001) CPT Codes 11950, 11951, 11952, 11954, 11980, 11981, 11982, 11983, 15780, | listed, no stance | Jan 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Liposuction for Lipedema and Lymphedema (SUR708.003) | listed, no stance | Jan 1, 2026 | 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 |
| Regence | Cosmetic and Reconstructive Procedures (Surgery 12) | listed, no stance | Jul 1, 2026 | payer document |
| Regence | Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES | listed, no stance | Nov 1, 2025 | payer document |
| Regence | Surgical Treatments for Lymphedema and Lipedema (Surgery 220) | listed, no stance | Dec 1, 2025 | 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 (MMP022.16) | listed, no stance | Sep 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 |
| 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 Kansas Only) (CS145KS.02) | 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 | 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 (2026T0636H) | listed, no stance | Jan 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 Mexico Only) (CS355NM.D) | listed, no stance | Feb 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, KY, NE, NY, VA, 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.