`15877` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 15877

86 of 87 payer prior-auth lists that name 15877 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, Blue Shield of California, Cigna, HealthSpring, Humana, Medicare, 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, 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
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Medicare	Prior Authorization Demonstration for Certain ASC Services	AZ	prior auth required		Feb 16, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	CA	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	FL	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	GA	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	MD	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	NY	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	OH	prior auth required		Feb 16, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	PA	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	TN	prior auth required		Jan 19, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
Medicare	Prior Authorization Demonstration for Certain ASC Services	TX	prior auth required		Feb 16, 2026	List of Ambulatory Surgical Center Services For Prior Authorization
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	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
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)
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
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	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 required		Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth required		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	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	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	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 required		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	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

Payer coverage policies that name 15877

15877 appears in 99 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, BlueCross BlueShield of South Carolina, 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	Breast Reconstructive Surgery (0185)	covered if criteria are met	Apr 22, 2026	payer document
Aetna	Breast Reduction Surgery and Gynecomastia Surgery (0017)	not covered	Mar 12, 2026	payer document
Aetna	Cosmetic Surgery and Procedures (0031)	covered if criteria are met	Jun 25, 2026	payer document
Aetna	Gender Affirming Surgery (0615)	not covered (range 15876-15879)	Sep 8, 2026	payer document
Aetna	Hyperhidrosis (0504)	covered if criteria are met	Aug 11, 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) CPT not covered for indications listed in the CPB	not covered	Jul 29, 2026	payer document
Aetna	Skin and Soft Tissue Substitutes (0244)	not covered (range 10040-19499)	Jul 29, 2026	payer document
Aetna	Vocal Cord Paralysis / Insufficiency Treatments (0253)	listed, no stance	Apr 15, 2026	payer document
Anthem	Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities (ANC.00009)	covered if criteria are met	Aug 13, 2026	payer document
Anthem	Mastectomy for Gynecomastia (CG-SURG-88)	not covered	Feb 19, 2026	payer document
Anthem	Panniculectomy and Abdominoplasty (CG-SURG-99)	not covered	Feb 19, 2026	payer document
Anthem	Reduction Mammaplasty (CG-SURG-71)	not covered	May 14, 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 Cross NC	Surgical Treatment for Lipedema	listed, no stance	Aug 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
Blue Shield of California	Panniculectomy, Abdominoplasty, and Surgical Management BSC7.04 of Diastasis Recti	listed, no stance		payer document
Blue Shield of California	\| Liposuction for Lipedema and Lymphedema (7.01.169)	listed, no stance		payer document
Blue Shield of California	\| Treatment of Hyperhidrosis (8.01.19)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Breast Surgical Procedures/Prosthesis (CAM 079) 11971 \| Removal of tissue expander(s) without insertion of prosthesis	listed, no stance	Sep 1, 2026	payer document
Capital Blue Cross	Cosmetic and Reconstructive Surgery (MP 1.004) Procedure codes	covered if criteria are met	Sep 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	Hyperhidrosis Treatments (CP.MP.62)	covered if criteria are met	Aug 1, 2026	payer document
Centene	Liposuction for Lipedema (CP.MP.244)	covered if criteria are met	Apr 1, 2026	payer document
Cigna	Breast Reconstruction Following Mastectomy or Lumpectomy (0178)	covered if criteria are met	Apr 15, 2026	payer document
Cigna	Breast Reconstruction Following Mastectomy or Lumpectomy (0178)	not covered	Apr 15, 2026	payer document
Cigna	Breast Reduction (0152)	covered if criteria are met	Nov 15, 2025	payer document
Cigna	Breast Reduction (0152)	unproven / investigational	Nov 15, 2025	payer document
Cigna	Gender Dysphoria Treatment (0266)	not covered	Sep 15, 2026	payer document
Cigna	Gynecomastia Surgery (0195)	not covered	Aug 15, 2026	payer document
Cigna	Hyperhidrosis: Surgical Treatments (0037)	covered if criteria are met	Jan 15, 2026	payer document
Cigna	Lymphedema and Lipedema Surgical Treatments (0531)	covered if criteria are met	Feb 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
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
Premera Blue Cross	Mastectomy for Gynecomastia (7.01.521)	listed, no stance	Apr 13, 2026	payer document
Premera Blue Cross	Panniculectomy and Excision of Redundant Skin (7.01.523)	listed, no stance	Jun 19, 2026	payer document
Premera Blue Cross	Surgical Treatments for Lymphedema and Lipedema (7.01.567)	listed, no stance	Oct 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	Reduction Mammaplasty (Surgery 60)	listed, no stance	Jun 1, 2026	payer document
Regence	Surgical Treatments for Lymphedema and Lipedema (Surgery 220)	listed, no stance	Dec 1, 2025	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (MMP022.16) Suction Assisted Lipectomy of Extremities/Liposuction for Lipedema	listed, no stance	Sep 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 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 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
UnitedHealthcare	Liposuction for Lipedema (CS203.G)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (2026T0625K)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Idaho Only) (CS203ID.C)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Kansas Only) (CS203KS.02)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Kentucky Only) (CS203KY.06)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Nebraska Only) (CS203NE.F)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for New Mexico Only) (CS203NM.C)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Ohio Only) (CS203OH.D)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Pennsylvania Only) (CS203PA.F)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Liposuction for Lipedema (for Tennessee Only) (CS203TN.F)	listed, no stance	Jan 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

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, Blue Cross and Blue Shield of Illinois
Apr 1, 2026: conditions changed, UnitedHealthcare
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Oct 1, 2025: conditions changed, UnitedHealthcare
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Jun 1, 2025: conditions changed, UnitedHealthcare Community Plan
Jun 1, 2025: conditions changed, UnitedHealthcare Community Plan
Apr 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, KY, ND, NE, NY, VA, WA.

CO: $598.60 (health_first_colorado), effective Jul 1, 2026
KY: $1894.49 (asc), effective Jan 1, 2026
LA: $217.00 (asc), effective Jul 1, 2012
MA: $1278.72 (asc), effective May 1, 2026
ND: $1116.80 (physician, facility), effective Aug 1, 2026
NE: $637.00 (asc), effective Jul 1, 2024
OH: $499.59 (physician), effective Jan 1, 2017
OK: $1728.38 (asc), effective Jan 1, 2026
VA: $953.57 (medical), effective Jul 1, 2011
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $1567.17 (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.

15877 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 15877

Payer coverage policies that name 15877

Recent prior-auth changes

Medicaid fee-for-service

`15877` CPT® code: payer coverage and prior authorization