21010 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21010

16 of 16 payer prior-auth lists that name 21010 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana, UnitedHealthcare, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)Federal Employee Program (FEP)AZprior auth under conditionsFEP Blue Focus onlySep 1, 2026Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
AetnaMedicare AdvantageAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
AetnaCommercialAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
CarePlus Health PlansCarePlus Health PlansFLprior auth requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
HumanaHumana D-SNP (FL)FLprior auth requiredJan 1, 20271 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
HumanaHumana D-SNP (IL)ILprior auth requiredJan 1, 2027Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
HumanaHumana D-SNP (IN)INprior auth requiredJan 1, 2027*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
HumanaHumana D-SNP (MI)MIprior auth requiredJan 1, 20271 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
HumanaHumana D-SNP (SC)SCprior auth requiredJan 1, 2027Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
HumanaHumana D-SNP (VA)VAprior auth requiredJan 1, 2027Virginia Prior Authorization and Notification List
HumanaHumana Healthy HorizonsINprior auth requiredJan 1, 20271 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
HumanaHumana MA and D-SNPAllprior auth requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
HumanaHumana Puerto Rico MA and Dual Medicare-MedicaidPRprior auth requiredNov 3, 2025Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
HumanaOak Street HealthAllprior auth requiredOak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name 21010

21010 appears in 24 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, BlueCross BlueShield of South Carolina, Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaDental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082)covered if criteria are metMar 18, 2026payer document
AetnaGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124)covered if criteria are met (range 21010-21030)Mar 19, 2026payer document
AetnaRemote Ischemic Conditioning (0814)listed, no stance (range 20000-29999)Nov 20, 2025payer document
AetnaSkin and Soft Tissue Substitutes (0244)not covered (range 20100-29999)Jul 29, 2026payer document
AetnaTemporomandibular Disorders (0028)covered if criteria are metMar 12, 2026payer document
AnthemTemporomandibular Disorders (CG-SURG-09)covered if criteria are metNov 6, 2025payer document
Blue Cross & Blue Shield of MississippiTemporomandibular Joint Disordercovered if criteria are metpayer document
Blue Cross Blue Shield of MassachusettsTemporomandibular joint disorder (035)listed, no stancepayer document
Blue Cross NCTemporomandibular Joint Dysfunction (TMJD)listed, no stanceOct 1, 2025payer document
Blue Shield of California| Temporomandibular Joint Disorder (2.01.21)listed, no stancepayer document
BlueCross BlueShield of South CarolinaTemporomandibular Joint Dysfunction (CAM 20121)listed, no stanceAug 1, 2026payer document
Premera Blue CrossTemporomandibular Joint Disorder (2.01.535)listed, no stanceApr 13, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (2026T0079RR)listed, no stanceMar 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (CS195.J)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Idaho Only) (CS195ID.C)listed, no stanceJul 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Indiana Only) (CS195IN.06)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Kansas Only) (CS195KS.02)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Kentucky Only) (CS195KY.10)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Nebraska Only) (CS195NE.J)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for New Jersey Only) (CS195NJ.G)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for North Carolina Only) (CSNCT0079.08)listed, no stanceJun 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Ohio Only) (CS195OH.E)listed, no stanceJul 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Pennsylvania Only) (CS195PA.H)listed, no stanceAug 1, 2026payer document
UnitedHealthcareTreatment of Temporomandibular Joint Disorders (for Tennessee Only) (CS195TN.H)listed, no stanceJun 1, 2026payer document

Recent prior-auth changes

  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Mar 1, 2026: conditions changed, UnitedHealthcare
  • Jan 1, 2026: PA removed, Humana
  • Jan 1, 2026: PA removed, Humana

Medicaid fee-for-service

Prior authorization required or conditional in IN.

  • AZ: $926.87 (asc), effective Oct 1, 2026
  • CO: $566.07 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $523.18 (physician, non-facility), effective Jan 1, 2026
  • IL: $498.90 (practitioner), effective Apr 1, 2024
  • IN: $578.20 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $247.87 (asc, facility), effective Aug 1, 1982
  • KY: $1445.19 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $896.80 (asc), effective May 1, 2026
  • MS: $1115.56 (comprehensive, facility), effective Oct 1, 2025
  • ND: $851.94 (physician, facility), effective Aug 1, 2026
  • NE: $1233.00 (asc), effective Jul 1, 2024
  • NY: $346.80 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $532.99 (physician), effective Jan 1, 2000
  • OK: $1318.48 (asc), effective Jan 1, 2026
  • TX: $886.62 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $582.75 (medical), effective Jul 1, 2026
  • VT: $2574.33 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1466.22 (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.