21209 CPT® code: payer coverage and prior authorization67 of 67 payer prior-auth lists that name 21209 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, Cigna, Humana, Molina Healthcare of Iowa, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
21209 appears in 52 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, Blue Shield of California, BlueCross BlueShield of South Carolina, Capital Blue Cross, 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 | 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 | Septoplasty and Rhinoplasty (0005) | listed, no stance | Mar 12, 2026 | 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 |
| Blue Shield of California | BSC7.02 | Gender Affirmation Surgery | listed, no stance | payer document | |
| Blue Shield of California | BSC7.03 | Orthognathic Surgery | listed, no stance | payer document | |
| Blue Shield of California | BSC7.08 | Cosmetic and Reconstructive Procedures | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Orthognathic Surgery (CAM 041) | listed, no stance | Jul 1, 2026 | payer document |
| Capital Blue Cross | Gender Affirming Surgery (MP 1.144) Procedure codes | covered if criteria are met | Apr 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 | Gender Dysphoria Treatment (0266) | not covered | Sep 15, 2026 | payer document |
| Cigna | Partial Rhinectomy, Rhinoplasty, Vestibular Stenosis Repair and Septoplasty (0119) | covered if criteria are met | Jul 1, 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 (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 (MMP022.16) Facial and Maxillofacial Reconstruction | listed, no stance | Sep 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 |
Prior authorization required or conditional in CO, IN, KY, LA, ND, NE, NY, WA, WV, 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.