`17108` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 17108

65 of 65 payer prior-auth lists that name 17108 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Cigna, Humana, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
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 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		Jan 1, 2023	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, 2023	Procedure Code List, Effective 1/1/2025
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	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
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	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	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required	site of care: site of service reviewed	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 required		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 required		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 required		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 Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 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
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 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	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
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	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth 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	Texas CHIP	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth required		Nov 1, 2016	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
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
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
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth required		Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth under conditions	PA not required with dx C43.0, C43.10, C43.111, C43.112, C43.121, C43.122 (+167 more)	Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 17108

17108 appears in 36 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, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Cosmetic Surgery and Procedures (0031)	covered if criteria are met (range 17106-17108)	Jun 25, 2026	payer document
Aetna	Cryoablation (0100)	listed, no stance (range 17000-17286)	Aug 4, 2026	payer document
Aetna	Dermabrasion, Chemical Peels, and Acne Surgery (0251)	listed, no stance (range 17000-17250)	Apr 15, 2026	payer document
Aetna	Lymphangioma and Infantile Hemangioma (0817)	covered if criteria are met (range 17106-17108)	Dec 3, 2025	payer document
Aetna	Pulsed Dye Laser Treatment (0559)	covered if criteria are met	Sep 18, 2026	payer document
Aetna	Rosacea (0547)	not covered	Aug 21, 2026	payer document
Aetna	Skin and Soft Tissue Substitutes (0244)	not covered (range 10040-19499)	Jul 29, 2026	payer document
Aetna	YAG Laser in Ophthalmology and Other Selected Indications (0354)	covered if criteria are met (range 17106-17108)	May 21, 2026	payer document
Anthem	Cosmetic and Reconstructive Services: Skin Related (ANC.00007)	covered if criteria are met (range 17106-17108)	Nov 6, 2025	payer document
Blue Cross & Blue Shield of Mississippi	Laser Treatment Of Congenital Port Wine Stain Hemangiomas (L.7.01.425)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Nonpharmacologic Treatment Of Rosacea	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Removal Of Benign Skin Lesions And Scars (L.7.01.412)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Rhode Island	Laser Treatment for Proliferative Vascular Lesions	covered if criteria are met	Jun 3, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Nonpharmacologic Treatment of Rosacea (462)	unproven / investigational		payer document
Blue Cross NC	Laser Treatment of Port Wine Stains	listed, no stance	Aug 1, 2026	payer document
Blue Cross NC	Non-Pharmacologic Treatment of Rosacea	listed, no stance	Sep 1, 2025	payer document
Cigna	Rosacea Procedures (0482)	not covered	Jun 15, 2025	payer document
Cigna	Scar Revision (0328)	covered if criteria are met	Jun 15, 2026	payer document
Cigna	Treatment of Cutaneous and Vascular Lesions (0313)	covered if criteria are met	May 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Nonpharmacologic Treatment of Rosacea (THE801.030) CPT Codes 15260, 15261, 15780, 15781, 15782, 15783, 15788, 15789, 15792,	listed, no stance	May 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	Nonpharmacologic Treatment of Rosacea (2.01.71)	listed, no stance	Feb 9, 2026	payer document
Regence	Cosmetic and Reconstructive Procedures (Surgery 12)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (MMP022.16) Light and Laser Therapy for Rosacea and Rhinophyma	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (2026T0337GG) Cutaneous Vascular Lesion	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (CS069.T) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Idaho Only) (CS069ID.C) Cutaneous Vascular Lesion	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Kansas Only) (CS069KS.02) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Kentucky Only) (CS069KY.06) Cutaneous Vascular Lesion	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Nebraska Only) (CS069NE.T) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for New Jersey Only) (CS069NJ.R) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for New Mexico Only) (CS069NM.C) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for North Carolina Only) (CSNCT0337.05) Cutaneous Vascular Lesion	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Ohio Only) (CS069OH.C) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Pennsylvania Only) (CS069PA.R) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Light and Laser Therapy (for Tennessee Only) (CS069TN.R) Cutaneous Vascular Lesion	listed, no stance	Feb 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: conditions changed, UnitedHealthcare
Oct 1, 2026: conditions changed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: conditions changed, Oxford Health Plans
Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, ND, VA, VT.

AZ: $196.71 (asc), effective Oct 1, 2026
CO: $525.59 (chp_plus, non-facility), effective Jul 1, 2026
FL: $367.43 (physician, facility), effective Jan 1, 2026
IL: $372.30 (practitioner), effective Jul 1, 2026
IN: $409.39 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $450.00 (asc, facility), effective Aug 1, 1982
KY: $350.94 (asc), effective Jan 1, 2026
LA: $506.02 (professional), effective Jul 1, 2025
MA: $300.32 (asc), effective May 1, 2026
MS: $278.44 (comprehensive, facility), effective Oct 1, 2025
ND: $347.11 (physician, facility), effective Aug 1, 2026
NE: $977.94 (physician, facility), effective Jul 1, 2026
NY: $363.72 (nurse_practitioner, facility), effective Jul 1, 2026
OH: $365.27 (physician, facility), effective Jan 1, 2024
OK: $320.17 (asc), effective Jan 1, 2026
TX: $280.45 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $392.94 (medical, facility), effective Jul 1, 2026
VT: $1602.06 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $269.64 (physician, facility), effective Jul 1, 2026
WY: $912.46 (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.

17108 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 17108

Payer coverage policies that name 17108

Recent prior-auth changes

Medicaid fee-for-service

`17108` CPT® code: payer coverage and prior authorization