31288 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 31288

55 of 55 payer prior-auth lists that name 31288 require prior authorization or set conditions: Aetna, Blue Shield of California, CarePlus Health Plans, Humana, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Shield of CaliforniaBlue Shield commercialCAprior auth under conditionsCalPERS ASO onlySep 1, 2026Prior Authorization List for Blue Shield
AetnaCommercialAllprior auth requiredsite of care: procedure and site of service reviewOct 1, 2026Participating provider precertification list for Aetna®
AetnaMedicare AdvantageAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
CarePlus Health PlansCarePlus Health PlansFLprior auth requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
HumanaHumana D-SNP (FL)FLprior auth requiredJan 1, 20271 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
HumanaHumana D-SNP (IL)ILprior auth requiredJan 1, 2027Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
HumanaHumana D-SNP (IN)INprior auth requiredJan 1, 2027*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
HumanaHumana D-SNP (MI)MIprior auth requiredJan 1, 20271 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
HumanaHumana D-SNP (SC)SCprior auth requiredJan 1, 2027Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
HumanaHumana D-SNP (VA)VAprior auth requiredJan 1, 2027Virginia Prior Authorization and Notification List
HumanaHumana MA and D-SNPAllprior auth requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
HumanaHumana Puerto Rico MA and Dual Medicare-MedicaidPRprior auth requiredNov 3, 2025Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
HumanaOak Street HealthAllprior auth under conditionsExcludes diagnostic nasal/sinus endoscopiesOak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
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
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 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 requiredMay 2, 2016Prior 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 requiredMay 2, 2016Prior 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 requiredMay 2, 2016Prior 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 PlanVirginia Cardinal Care LTSSVAprior auth requiredOct 1, 2026Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
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 requiredSep 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 31288

31288 appears in 25 coverage policies from Aetna, Anthem, Blue Cross NC, BlueCross BlueShield of South Carolina, Cigna, Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaCoblation (0475)listed, no stance (range 31254-31288)Jul 2, 2026payer document
AetnaDevices for Post-Operative Use Following Endoscopic Sinus Surgery (0840)listed, no stance (range 31237-31294)Dec 4, 2025payer document
AetnaMyringotomy and Tympanostomy Tube (0418)listed, no stance (range 31231-31297)Jun 30, 2026payer document
AetnaSeptoplasty and Rhinoplasty (0005)listed, no stance (range 31237-31294)Mar 12, 2026payer document
AetnaSinus Surgeries (0937)covered if criteria are metApr 10, 2026payer document
AetnaTezepelumab-ekko (Tezspire) (1003)listed, no stance (range 30000-31299)Aug 6, 2026payer document
AnthemFunctional Endoscopic Sinus Surgery (FESS) (CG-SURG-24)covered if criteria are metMay 14, 2026payer document
Blue Cross NCProfessional Pathology Billing Requirements AHS – R2169listed, no stance (range 3011F-3210F)Mar 1, 2024payer document
Blue Cross NCSurgical Treatment of Sinus Diseaselisted, no stanceFeb 1, 2026payer document
BlueCross BlueShield of South CarolinaFunctional Endoscopic Sinus Surgery for Chronic Rhinosinusitis (CAM 701155)listed, no stance (range 31231-31294)Nov 1, 2025payer document
CignaDiagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy (0554)covered if criteria are metSep 15, 2026payer document
Premera Blue CrossSinus Surgery in Adults (7.01.559)
Page | 10 of 37 | ∞		listed, no stanceOct 14, 2026payer document
UnitedHealthcareEar, Nose, and Throat Procedures (MMP060.17)
Functional Endoscopic Sinus Surgery (FESS)		listed, no stanceSep 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (2026T0571U)listed, no stanceJul 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (CS138.T)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for Idaho Only) (CS138ID.D)listed, no stanceSep 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for Kansas Only) (CS138KS.03)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for Kentucky Only) (CS138KY.13)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for Nebraska Only) (CS138NE.U)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for New Jersey Only) (CS138NJ.O)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for New Mexico Only) (CS138NM.D)listed, no stanceAug 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for North Carolina Only) (CSNCT0571.06)listed, no stanceAug 1, 2025payer document
UnitedHealthcareSinus Surgeries and Interventions (for Ohio Only) (CS138OH.D)listed, no stanceSep 1, 2026payer document
UnitedHealthcareSinus Surgeries and Interventions (for Pennsylvania Only) (CS138PA.Q)listed, no stanceAug 1, 2025payer document
UnitedHealthcareSinus Surgeries and Interventions (for Tennessee Only) (CS138TN.Q)listed, no stanceAug 1, 2026payer document

Recent prior-auth changes

  • May 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Apr 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Mar 1, 2025: PA added, Rocky Mountain Health Plans
  • Mar 1, 2025: PA added, Rocky Mountain Health Plans

Medicaid fee-for-service

  • AZ: $1715.49 (asc), effective Oct 1, 2026
  • CO: $190.27 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $161.08 (physician, non-facility), effective Jan 1, 2026
  • IL: $229.47 (practitioner), effective Apr 1, 2024
  • IN: $179.29 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KS: $225.00 (asc, facility), effective Jan 1, 1994
  • KY: $2392.56 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1611.51 (asc), effective May 1, 2026
  • MS: $1940.67 (comprehensive, facility), effective Oct 1, 2025
  • ND: $1410.42 (physician, facility), effective Aug 1, 2026
  • NE: $1000.00 (asc), effective Jul 1, 2024
  • NY: $135.99 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $233.54 (physician), effective Jan 1, 2010
  • OK: $2182.78 (asc), effective Jan 1, 2026
  • TX: $1630.12 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
  • VA: $171.59 (medical), effective Jul 1, 2026
  • VT: $5479.84 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $339.40 (asc), effective Jul 1, 2026
  • WY: $3121.07 (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.