21320 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 21320

20 of 20 payer prior-auth lists that name 21320 require prior authorization or set conditions: Neighborhood Health Partnership, UnitedHealthcare, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Neighborhood Health PartnershipNeighborhood Health PartnershipFLprior auth under conditionssite of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WISep 1, 2026Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth under conditionssite of care: outpatient hospitalSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare Community PlanAHCCCS Complete Care (ACC)AZprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community PlanALTCS Developmentally DisabledAZprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth under conditionssite of care: outpatient hospitalSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
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 PlanMississippi CHIPMSprior auth under conditionssite of care: outpatient hospitalApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth under conditionssite of care: outpatient hospitalApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community PlanMissouri MedicaidMOprior auth under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth under conditionssite of care: outpatient hospital, ASCNov 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 under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth under conditionssite of care: outpatient hospitalJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth under conditionssite of care: outpatient hospitalMay 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 under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth under conditionssite of care: outpatient hospitalJul 1, 2020Prior 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 under conditionssite of care: outpatient hospitalJul 1, 2020Prior 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 under conditionssite of care: outpatient hospitalJul 1, 2020Prior 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 under conditionssite of care: outpatient hospitalJul 1, 2020Prior 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 New YorkNYprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth under conditionssite of care: outpatient hospitalOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023

Payer coverage policies that name 21320

21320 appears in 4 coverage policies from Aetna, Regence.

PayerPolicyRole in policyReviewedDocument
AetnaGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services (0124)covered if criteria are met (range 21295-21497)Mar 19, 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
RegenceSurgical Site of Care – Hospital Outpatient (Utilization Management 19)listed, no stanceMay 1, 2026payer document

Recent prior-auth changes

  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, Oxford Health Plans
  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Oct 1, 2026: PA removed, UnitedHealthcare
  • Aug 1, 2026: conditions changed, UnitedHealthcare
  • Jul 1, 2026: conditions changed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in WV.

  • AZ: $926.87 (asc), effective Oct 1, 2026
  • CO: $83.20 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $65.72 (physician, facility), effective Jan 1, 2026
  • IL: $93.38 (practitioner), effective Apr 1, 2024
  • IN: $73.15 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $231.00 (asc, facility), effective Aug 1, 1982
  • KY: $1445.19 (asc), effective Jan 1, 2026
  • LA: $182.30 (asc), effective Jul 1, 2012
  • MA: $896.80 (asc), effective May 1, 2026
  • MS: $1115.56 (comprehensive, facility), effective Oct 1, 2025
  • ND: $851.94 (physician, facility), effective Aug 1, 2026
  • NE: $413.00 (asc), effective Jul 1, 2024
  • NY: $66.26 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $55.52 (physician, facility), effective Jan 1, 2024
  • OK: $1318.48 (asc), effective Jan 1, 2026
  • TX: $886.62 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $70.89 (medical, facility), effective Jul 1, 2026
  • VT: $2574.33 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $1466.22 (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.