`21208` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21208

81 of 81 payer prior-auth lists that name 21208 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of Iowa, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth required	Not covered for gender dysphoria (unless in treatment as of 1/1/26); PA for other dx	Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required		Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required		Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
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
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
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	Basic Standard	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
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required		Oct 1, 2026	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required		Jan 1, 2025	Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Jan 1, 2025	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 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
Humana	Humana Healthy Horizons	LA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
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
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required		Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth under conditions	only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890	Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
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
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare West commercial plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana Hoosier Care Connect	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana PathWays for Aging (MLTSS)	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior 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 Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior 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 Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	North Carolina Medicaid	NC	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior 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 Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Jan 1, 2015	Prior 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 Plan	Texas STAR	TX	prior auth required		Jan 1, 2015	Prior 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 Plan	Texas STAR Kids	TX	prior auth required		Nov 1, 2016	Prior 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 Plan	Texas STAR+PLUS	TX	prior auth required		Jan 1, 2015	Prior 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 Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth required		Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023

Payer coverage policies that name 21208

21208 appears in 48 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, BlueCross BlueShield of South Carolina, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, 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	Gender Affirming Surgery (0615)	not covered	Sep 8, 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 21141-21268)	Mar 19, 2026	payer document
Aetna	Obstructive Sleep Apnea in Adults (0004)	covered if criteria are met	Oct 6, 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	Temporomandibular Disorders (0028)	not covered (range 21208-21209)	Mar 12, 2026	payer document
Anthem	Mandibular/Maxillary (Orthognathic) Surgery (CG-SURG-84)	covered if criteria are met	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Orthognathic Surgery Overbiteunderbite (L.7.01.409)	listed, no stance		payer document
Blue Cross & Blue Shield of Rhode Island	Gender Affirming Care MEDICAL COVERAGE POLICY \| 5	covered if criteria are met	Apr 1, 2026	payer document
Blue Cross & Blue Shield of Rhode Island	Orthognathic Surgery MEDICAL COVERAGE POLICY \| 1	covered if criteria are met	Mar 18, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Gender Affirming Services (Transgender Services) (189)	listed, no stance		payer document
Blue Cross NC	Sex Trait Modification Procedures For Gender Affirming Care	listed, no stance	Apr 1, 2026	payer document
BlueCross BlueShield of South Carolina	Orthognathic Surgery (CAM 041)	listed, no stance	Jul 1, 2026	payer document
Centene	Gender-Affirming Procedures (CP.MP.95)	covered if criteria are met	Jul 1, 2026	payer document
Centene	Orthognathic Surgery (CP.MP.202)	covered if criteria are met	Aug 1, 2026	payer document
Cigna	Bone Graft Substitutes (0118)	listed, no stance	Feb 15, 2026	payer document
Cigna	Gender Dysphoria Treatment (0266)	not covered	Sep 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Orthognathic Surgery (SUR705.030) CPT Codes 21085, 21110, 21120, 21122, 21123, 21125, 21127, 21141, 21142,	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Gender Transition/Affirmation Surgery and Related Services (7.01.557) Page \| 31 of 59 \| ∞	listed, no stance	Jul 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) Page \| 6 of 19 \| ∞	listed, no stance	May 12, 2026	payer document
Regence	Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES	listed, no stance	Nov 1, 2025	payer document
Regence	Orthognathic Surgery (Surgery 137)	listed, no stance	Feb 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (MMP022.16) Facial and Maxillofacial Reconstruction	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (MP.007.33)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (CS027.AD)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic 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 stance	May 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Kansas Only) (CS027KS.03)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Kentucky Only) (CS027KY.13)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Nebraska Only) (CS027NE.U)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for New Jersey Only) (CS027NJ.W)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for New Mexico Only) (CS027NM.E)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for North Carolina Only) (CSNC.MP.007.10)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Ohio Only) (CS027OH.E)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Pennsylvania Only) (CS027PA.AD)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Cosmetic and Reconstructive Procedures (for Tennessee Only) (CS027TN.AB)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (2026T0580U)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (CS145.T)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for Indiana Only) (CS145IN.11)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for Kansas Only) (CS145KS.02)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for New Jersey Only) (CS145NJ.L)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for New Mexico Only) (CS145NM.D)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for North Carolina Only) (CSNCT0145.04)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for Ohio Only) (CS145OH.C)	listed, no stance	Sep 1, 2024	payer document
UnitedHealthcare	Gender Dysphoria Treatment (for Pennsylvania Only) (CS145PA.P)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Gender Dysphoria and Gender Reassignment Surgery (MMP365.14) Other Ancillary Services	listed, no stance	Sep 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Nov 1, 2025: conditions changed, Neighborhood Health Partnership
Oct 1, 2025: conditions changed, Neighborhood Health Partnership
Dec 1, 2021: PA added, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, FL, IN, KY, LA, ND, NE, NY, VT, WA, WV, WY.

AZ: $1943.46 (asc), effective Oct 1, 2026
CO: $486.37 (chp_plus, non-facility), effective Jul 1, 2026
FL: $521.62 (physician, facility), effective Jan 1, 2026
IL: $709.93 (practitioner), effective Apr 1, 2024
IN: $580.52 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $1000.00 (asc, facility), effective Aug 1, 1982
KY: $2953.46 (asc), effective Jan 1, 2026
LA: $265.13 (asc), effective Jul 1, 2012
MA: $2504.67 (asc), effective May 1, 2026
MS: $2992.14 (comprehensive, facility), effective Oct 1, 2025
ND: $1741.07 (physician, facility), effective Aug 1, 2026
NE: $1233.00 (asc), effective Jul 1, 2024
NY: $394.43 (physician_surgery, facility), effective Jul 1, 2026
OH: $589.20 (physician, facility), effective Jan 1, 2024
OK: $2694.50 (asc), effective Jan 1, 2026
TX: $2706.07 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $581.02 (medical, facility), 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.

21208 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21208

Payer coverage policies that name 21208

Recent prior-auth changes

Medicaid fee-for-service

`21208` CPT® code: payer coverage and prior authorization