19355 CPT® code: payer coverage and prior authorization54 of 54 payer prior-auth lists that name 19355 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | FEP Blue Focus only | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 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 | |
| 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 | |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| 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 | OH | prior auth required | Jan 1, 2027 | 555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification 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 | |
| Humana | Humana Healthy Horizons | SC | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical | |
| Humana | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth under conditions | no PA with breast cancerncer dx | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth under conditions | no PA with breast cancerncer dx | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth under conditions | no PA with breast cancerncer dx | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth under conditions | no PA with breast cancerncer dx | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth under conditions | no PA with breast cancerncer dx | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth under conditions | no PA with breast cancerncer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth under conditions | no PA with breast cancerncer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Exchange | MI | prior auth under conditions | no PA with breast cancer dx | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth under conditions | no PA with breast cancerncer dx | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth under conditions | no PA with breast cancerncer dx | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth under conditions | no PA with breast cancerncer dx | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth under conditions | no PA with breast cancerncer dx | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth under conditions | no PA with breast cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth under conditions | no PA with breast cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Exchange | OH | prior auth under conditions | no PA with breast cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth under conditions | no PA with breast cancerncer dx | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth under conditions | no PA with breast cancerncer dx | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth under conditions | no PA with breast cancerncer dx | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth under conditions | no PA with breast cancerncer dx | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth under conditions | no PA with breast cancerncer dx | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth under conditions | no PA with breast cancerncer dx | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth under conditions | no PA with breast cancerncer dx | 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 | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 | 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 | UnitedHealthcare Connected (Texas MMP) | TX | prior auth under conditions | Dx group: Breast Reconstructi on; Prior authorization is not required for these codes with Breast Reconstruction DX codes. | 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 |
19355 appears in 28 coverage policies from Aetna, Blue Cross Blue Shield of Massachusetts, 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 | Breast Implant Removal (0142) | listed, no stance (range 19316-19380) | Mar 19, 2026 | payer document |
| Aetna | Breast Reconstructive Surgery (0185) | covered if criteria are met | Apr 22, 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 | Nerve Blocks (0863) | listed, no stance (range 19316-19380) | Jul 23, 2026 | payer document |
| Aetna | Nerve Blocks (0863) | listed, no stance (range 19316-19396) | Jul 23, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 10040-19499) | Jul 29, 2026 | payer document |
| Blue Cross Blue Shield of Massachusetts | Reconstructive Breast Surgery (428) | listed, no stance | payer document | |
| Blue Shield of California | BSC7.08 | Cosmetic and Reconstructive Procedures | listed, no stance | payer document | |
| Capital Blue Cross | Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras (MP 1.103) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| Centene | Cosmetic and Reconstructive Procedures Reference Number: CP.MP.31 (CP.MP.31) | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Breast Reconstruction Following Mastectomy or Lumpectomy (0178) | covered if criteria are met | Apr 15, 2026 | payer document |
| Cigna | Breast Reduction (0152) | not covered | Nov 15, 2025 | 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 |
| Premera Blue Cross | Cosmetic and Reconstructive Services Page | 8 of 20 | ∞ | listed, no stance | Apr 1, 2026 | payer document |
| Regence | Cosmetic and Reconstructive Procedures (Surgery 12) | listed, no stance | Jul 1, 2026 | payer document |
| Regence | Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (Surgery 40) NOTE | listed, no stance | Oct 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (CS011.W) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (MP.003.29) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Idaho Only) (CS011ID.C) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Indiana Only) (CS011IN.10) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Kansas Only) (CS011KS.02) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Kentucky Only) (CS011KY.13) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Nebraska Only) (CS011NE.V) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for New Jersey Only) (CS011NJ.T) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for New Mexico Only) (CS011NM.C) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for North Carolina Only) (CSNC.MP.003.07) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Ohio Only) (CS011OH.C) | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Pennsylvania Only) (CS011PA.W) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Breast Reconstruction (for Tennessee Only) (CS011TN.T) | listed, no stance | Nov 1, 2025 | payer document |
Prior authorization required or conditional in CO, IN, ND, NE, VA, VT, WA, WV.
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.