21088 CPT® code: payer coverage and prior authorization10 of 10 payer prior-auth lists that name 21088 require prior authorization or set conditions: Blue Shield of California, Cigna, Humana, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| 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 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 | |
| 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 | |
| Humana | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| 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 |
21088 appears in 15 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, Capital Blue Cross, Cigna, Premera Blue Cross.
| 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 | Orthognathic Surgery (0095) | covered if criteria are met | Mar 18, 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 |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Blue Shield of California | BSC7.02 | Gender Affirmation Surgery | listed, no stance | payer document | |
| Blue Shield of California | BSC7.08 | Cosmetic and Reconstructive Procedures | listed, no stance | payer document | |
| Capital Blue Cross | Cosmetic and Reconstructive Surgery (MP 1.004) Procedure codes | covered if criteria are met | Sep 1, 2026 | payer document |
| Cigna | Prosthetic Devices (0536) | listed, no stance | Jan 15, 2026 | payer document |
| Premera Blue Cross | Cosmetic and Reconstructive Services Page | 9 of 20 | ∞ | listed, no stance | Apr 1, 2026 | payer document |
| Premera Blue Cross | Orthodontic Services for Treatment of Congenital Craniofacial Anomalies (9.02.500) | listed, no stance | Jun 22, 2026 | payer document |
| Premera Blue Cross | Orthognathic Surgery (9.02.501) | listed, no stance | May 12, 2026 | payer document |
Prior authorization required or conditional in CO, KY, 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.