21080 CPT® code: payer coverage and prior authorization4 of 4 payer prior-auth lists that name 21080 require prior authorization or set conditions: Cigna, Humana, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Cigna | ACA/IFP | All | prior auth required | Oct 25, 2019 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Oct 25, 2019 | Master Precertification List (For Health Care Providers) | |
| 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 | |
| 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 |
21080 appears in 21 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, Cigna, UnitedHealthcare.
| 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 | Facial Prostheses, External (0620) | covered if criteria are met | Sep 3, 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 21034-21116) | Mar 19, 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 |
| Aetna | Stereolithographic Models and Implants (0613) | listed, no stance (range 21076-21088) | Sep 3, 2026 | payer document |
| Aetna | Temporomandibular Disorders (0028) | covered if criteria are met | Mar 12, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Blue Shield of California | BSC2.01 | Cleft Palate - Dental Related Services | listed, no stance | payer document | |
| Cigna | Intraoral Prostheses (0584) | covered if criteria are met | Aug 15, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (MP.013.25) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (CS088.X) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Idaho Only) (CS088ID.D) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Kansas Only) (CS088KS.04) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Kentucky Only) (CS088KY.11) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Nebraska Only) (CS088NE.W) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for New Jersey Only) (CS088NJ.W) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for New Mexico Only) (CS088NM.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Ohio Only) (CS088OH.E) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Pennsylvania Only) (CS088PA.W) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Orthognathic (Jaw) Surgery (for Tennessee Only) (CS088TN.X) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in CO, VA, WA, 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.