21025 CPT® code: payer coverage and prior authorization6 of 6 payer prior-auth lists that name 21025 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Cigna, Humana.
| 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 | Only gender dysphoria dx, members in treatment as of 1/1/26 | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| 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 | 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 | |
| Humana | Humana Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification |
21025 appears in 7 coverage policies from Aetna, Cigna, Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (0082) | covered if criteria are met | Mar 18, 2026 | payer document |
| Aetna | General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124) | covered if criteria are met (range 21010-21030) | Mar 19, 2026 | payer document |
| Aetna | Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO (0642) | not covered | Sep 9, 2026 | payer document |
| Aetna | Remote Ischemic Conditioning (0814) | listed, no stance (range 20000-29999) | Nov 20, 2025 | payer document |
| Aetna | Skin and Soft Tissue Substitutes (0244) | not covered (range 20100-29999) | Jul 29, 2026 | payer document |
| Cigna | Gender Dysphoria Treatment (0266) | not covered | Sep 15, 2026 | payer document |
| Regence | Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES | listed, no stance | Nov 1, 2025 | payer document |
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.