15879 CPT® code: payer coverage and prior authorization67 of 68 payer prior-auth lists that name 15879 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) | 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 | |
| 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 Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| Cigna | Other Services | All | prior auth required | 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 | |
| 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 | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| 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 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 | 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 | Pennsylvania CHIP | PA | prior auth under conditions | *Gender Dysphoria may apply | 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 | *Gender Dysphoria may apply | 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 | 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 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | 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 required | 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 required | Jan 1, 2015 | 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 | Virginia Cardinal Care LTSS | VA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 |
15879 appears in 77 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 | Cosmetic Surgery and Procedures (0031) Thermal therapy (e.g., radiofrequency (ThermiVa and Viveve procedures) and laser), Laviv (azficel-T) | not covered (range 15878-15879) | 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 Trunk, Groin, and Extremities (ANC.00009) | 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) | listed, no stance | 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 Rhode Island | Surgical Treatments for Lymphedema and Lipedema MEDICAL COVERAGE POLICY | 11 | not covered | Sep 3, 2025 | 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 Cross NC | Surgical Treatments for Lymphedema | listed, no stance | Nov 1, 2025 | 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 | BSC7.18 Immediate and Delayed Lymphatic Reconstruction Surgery | listed, no stance | payer document | |
| Blue Shield of California | | Liposuction for Lipedema and Lymphedema (7.01.169) | 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 |
| Centene | Liposuction for Lipedema (CP.MP.244) | covered if criteria are met | Apr 1, 2026 | payer document |
| Cigna | Gender Dysphoria Treatment (0266) | not covered | Sep 15, 2026 | payer document |
| Cigna | Lymphedema and Lipedema Surgical Treatments (0531) | covered if criteria are met | Feb 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 | 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 | 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 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 | 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 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 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 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, IN, KY, NE, NY, 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.