21181 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21181

48 of 48 payer prior-auth lists that name 21181 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, 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)
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Neighborhood Health PartnershipNeighborhood Health PartnershipFLprior auth requiredSep 1, 2026Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health PlansOxford Health PlansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Health Plans CHP+COprior auth requiredOct 1, 2026Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Health Plans Prime / RAECOprior auth requiredOct 1, 2026Rocky Mountain Health Plans PRIME Effective October 1, 2026
Rocky Mountain Health PlansRocky Mountain Medicare Advantage D-SNPCOprior auth requiredFeb 1, 2025Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
SurestSurest health plansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcareUnitedHealthcare CommercialAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Individual Exchange plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Mid-Atlantic Health PlansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare West commercial plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026
UnitedHealthcareUnitedHealthcare of the River ValleyAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community PlanAHCCCS Complete Care (ACC)AZprior auth requiredOct 1, 2026Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community PlanALTCS Developmentally DisabledAZprior auth requiredOct 1, 2026Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community PlanALTCS Long Term CareAZprior auth requiredOct 1, 2026Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community PlanKanCareKSprior auth requiredOct 1, 2026Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community PlanLouisiana Medicaid (Healthy Louisiana)LAprior auth requiredJan 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community PlanMassachusetts OneCareMAprior auth requiredNov 1, 2025Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO)MAprior auth requiredNov 1, 2025CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community PlanMassachusetts Senior Care Options (SCO) and OneCareMAprior auth requiredOct 1, 2026Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community PlanMichigan Medicaid, Healthy Michigan Plan, CSHCSMIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community PlanMinnesota Metro MedicaidMNprior auth requiredOct 1, 2024Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community PlanMississippi CHIPMSprior auth requiredApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth requiredApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community PlanMissouri MedicaidMOprior auth requiredJul 1, 2026Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community PlanNebraska Heritage HealthNEprior auth requiredJul 1, 2026Prior 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 PlanNew Jersey FamilyCareNJprior auth requiredOct 1, 2026Prior 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 PlanNew Mexico Turquoise CareNMprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth requiredNov 1, 2025Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community PlanPennsylvania CHIPPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth requiredMay 1, 2026Prior 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 PlanTennCareTNprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth requiredJan 1, 2015Prior 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 PlanTexas STARTXprior auth requiredJan 1, 2015Prior 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 PlanTexas STAR KidsTXprior auth requiredNov 1, 2016Prior 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 PlanTexas STAR+PLUSTXprior auth requiredJan 1, 2015Prior 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 PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of Hawaii (QUEST Integration)HIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 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
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJan 1, 2015Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community PlanVirginia Cardinal Care MedicaidVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth requiredOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community PlanWisconsin BadgerCare Plus and Medicaid SSIWIprior auth under conditionsPA not required with dx C43.0, C43.10, C43.111, C43.112, C43.121, C43.122 (+167 more)Sep 1, 2026Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 21181

21181 appears in 20 coverage policies from Aetna, Centene, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaDistraction Osteogenesis for Craniofacial Defects (0549)listed, no stance (range 21120-21196)Jul 30, 2026payer document
AetnaGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124)covered if criteria are met (range 21141-21268)Mar 19, 2026payer document
AetnaOrthognathic Surgery (0095)covered if criteria are metMar 18, 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
AetnaStereolithographic Models and Implants (0613)listed, no stance (range 21120-21196)Sep 3, 2026payer document
CenteneCosmetic and Reconstructive Procedures Reference Number: CP.MP.31 (CP.MP.31)covered if criteria are metAug 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (MMP022.16)
Facial and Maxillofacial Reconstruction		listed, no stanceSep 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (MP.007.33)listed, no stanceJun 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (CS027.AD)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Idaho Only) (CS027ID.C)
The following codes may be Cosmetic; review is required to determine if considered Cosmetic or		listed, no stanceMay 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Kansas Only) (CS027KS.03)listed, no stanceSep 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Kentucky Only) (CS027KY.13)listed, no stanceAug 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Nebraska Only) (CS027NE.U)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for New Jersey Only) (CS027NJ.W)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for New Mexico Only) (CS027NM.E)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for North Carolina Only) (CSNC.MP.007.10)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Ohio Only) (CS027OH.E)listed, no stanceAug 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Pennsylvania Only) (CS027PA.AD)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Tennessee Only) (CS027TN.AB)listed, no stanceAug 1, 2026payer document

Recent prior-auth changes

  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Apr 1, 2026: conditions changed, UnitedHealthcare
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
  • Oct 1, 2025: conditions changed, Rocky Mountain Health Plans
  • Oct 1, 2025: conditions changed, UnitedHealthcare
  • Oct 1, 2025: conditions changed, Rocky Mountain Health Plans
  • Jun 1, 2025: conditions changed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in CO, ND, WV, WY.

  • AZ: $1943.46 (asc), effective Oct 1, 2026
  • CO: $595.06 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $523.18 (physician, non-facility), effective Jan 1, 2026
  • IL: $724.58 (practitioner), effective Apr 1, 2024
  • IN: $570.47 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $662.00 (asc, facility), effective Jul 1, 1978
  • KY: $2953.46 (asc), effective Jan 1, 2026
  • LA: $265.13 (asc), effective Jul 1, 2012
  • MA: $1909.57 (asc), effective May 1, 2026
  • MS: $2333.88 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1741.07 (physician, facility), effective Aug 1, 2026
  • NE: $1233.00 (asc), effective Jul 1, 2024
  • NY: $347.82 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $485.44 (physician), effective Jan 1, 2024
  • OK: $2694.50 (asc), effective Jan 1, 2026
  • TX: $1954.22 (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: $4596.52 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $366.60 (asc), effective Jul 1, 2026
  • WY: $2617.97 (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.