19367 CPT® code: payer coverage and prior authorization51 of 51 payer prior-auth lists that name 19367 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Humana, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
| 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 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 | |
| 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 | LA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate | |
| 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 | Humana Healthy Horizons | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| 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 under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 | 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 |
| Surest | Surest health plans | All | prior auth under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | Oct 1, 2026 | Prior Authorization Requirements for Surest 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 under conditions | PA not required with dx C50.019, C50.011, C50.012, C50.111, C50.112, C50.119 (+67 more) | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth under conditions | PA not required with dx C50.019, C50.011, C50.012, C50.111, C50.112, C50.119 (+67 more) | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth under conditions | PA not required with dx C50.019, C50.011, C50.012, C50.111, C50.112, C50.119 (+67 more) | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth under conditions | PA not required with dx C50.019, C50.011, C50.012, C50.111, C50.112, C50.119 (+67 more) | 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 under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 under conditions | Prior authorization is not required for these codes with Breast Reconstruction DX codes. | 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 under conditions | Dx group: tion DX Codes | 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 under conditions | Prior authorization is not required for these codes with Breast Reconstruction DX codes. | 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 under conditions | Dx group: ion DX Codes | 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 under conditions | PA not required with dx C50.019, C50.011, C50.012, C50.111, C50.112, C50.119 (+67 more) | 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 | Virginia Cardinal Care LTSS | VA | prior auth under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth under conditions | PA not required with dx C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 more) | 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 C50.011, C50.012, C50.019, C50.021, C50.022, C50.029 (+67 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 |
19367 appears in 29 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, BlueCross BlueShield of South Carolina, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Acupuncture and Dry Needling (0135) | listed, no stance | Mar 25, 2026 | payer 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 | Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy (0227) | covered if criteria are met | Apr 14, 2026 | payer document |
| Aetna | Cosmetic Surgery and Procedures (0031) | covered if criteria are met (range 19357-19396) | Jun 25, 2026 | payer document |
| Aetna | Indocyanine Green Angiography (0111) | listed, no stance | Mar 18, 2026 | payer document |
| Aetna | Magnetic Resonance Imaging (MRI) of the Breast (0105) | listed, no stance (range 19357-19369) | Aug 6, 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 | Pectus Excavatum and Poland's Syndrome: Surgical Correction (0272) | covered if criteria are met | Apr 17, 2026 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | listed, no stance (range 19357-19369) | Jul 29, 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 Mississippi | Breast Reconstruction Following Mastectomy (L.7.01.424) | covered if criteria are met | payer document | |
| Blue Cross Blue Shield of Massachusetts | Reconstructive Breast Surgery (428) | listed, no stance | payer document | |
| Blue Cross NC | Breast Surgeries | listed, no stance | Aug 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Breast Surgical Procedures/Prosthesis (CAM 079) 19355 | Correction of inverted nipples | listed, no stance | 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 |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Reconstructive Breast Surgery (SUR716.011) CPT Codes 11920, 11921, 11922, 11970, 11971, 15734, 15756, 15757, 15769, | listed, no stance | May 15, 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 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, FL, KY, LA, NE, VA, VT, WV, WY.
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.