`38242` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 38242

94 of 94 payer prior-auth lists that name 38242 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Blue Shield of California, Blue Shield of California Promise Health Plan, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, and others.

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)	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
Cigna	ACA/IFP	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required		Jan 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 New Mexico	Turquoise Care (New Mexico Medicaid)	NM	prior auth required		Oct 1, 2026	New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
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)
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South Carolina	Medicare Advantage	SC	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2026	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Sep 1, 2019	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicare Advantage	UT	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of Washington	Medicare Advantage	WA	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of Wisconsin	Medicare Advantage	WI	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)	Molina national (MHI) Medicare grid	All	prior auth required		Oct 1, 2021	Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
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 required		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	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida 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 Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth required		Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements 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	Massachusetts OneCare	MA	prior auth required		Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth required		Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth required		Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 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	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	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

Payer coverage policies that name 38242

38242 appears in 81 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, 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), Regence.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Age-Related Macular Degeneration (0765)	not covered	Jan 14, 2026	payer document
Aetna	Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788)	not covered	Nov 19, 2025	payer document
Aetna	Blinatumomab (Blincyto) (0891)	listed, no stance	Oct 30, 2025	payer document
Aetna	Clofarabine (0867)	listed, no stance	Dec 24, 2025	payer document
Aetna	Donor Lymphocyte Infusion (0638)	covered if criteria are met	Sep 29, 2026	payer document
Aetna	Epilepsy Surgery (0394)	not covered	Jun 23, 2026	payer document
Aetna	Erectile Dysfunction and Peyronie's Disease (0007)	not covered	Jul 29, 2026	payer document
Aetna	Erythropoiesis Stimulating Agents (0195)	not covered (range 38240-38243)	Jan 20, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia (0674)	covered if criteria are met	Oct 7, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Inherited Metabolic Disorders and Genetic Diseases (0871)	covered if criteria are met	Dec 22, 2025	payer document
Aetna	Hematopoietic Cell Transplantation for Myelodysplastic Syndrome (0836)	covered if criteria are met	Dec 9, 2025	payer document
Aetna	Hematopoietic Cell Transplantation for Myelofibrosis (0838)	covered if criteria are met	Dec 9, 2025	payer document
Aetna	Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496)	covered if criteria are met	Aug 6, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Selected Leukemias (0640)	covered if criteria are met	Sep 11, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Solid Tumors in Adults (0811)	not covered	Dec 3, 2025	payer document
Aetna	Hematopoietic Colony-Stimulating Factors (CSFs) (0055)	listed, no stance	Jul 16, 2026	payer document
Aetna	Huntington's Disease (0614)	not covered	Sep 24, 2026	payer document
Aetna	Hypoxic Ischemic Encephalopathy (0812)	not covered	Nov 20, 2025	payer document
Aetna	Marnetegragene Autotemcel (Kresladi) (1102)	listed, no stance (range 38240-38243)	Jul 13, 2026	payer document
Aetna	Non-myeloablative Hematopoietic Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant) (0634)	covered if criteria are met	Sep 25, 2026	payer document
Aetna	Palifermin (Kepivance) (0851)	listed, no stance	Dec 22, 2025	payer document
Aetna	Recurrent Pregnancy Loss (0348)	not covered	Jun 23, 2026	payer document
Aetna	Temporomandibular Disorders (0028)	not covered	Mar 12, 2026	payer document
Anthem	Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation (CG-TRANS-03)	covered if criteria are met	May 14, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Allogeneic Hematopoietic Cell Transplantation For Genetic Diseases And Acquired Anemias (L.8.01.412)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Allogeneic Hematopoietic Cell Transplantation For Myelodysplastic Syndromes And Myeloproliferative Neoplasms	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Autologous Hematopoietic Stemcell Transplantation For Malignant Astrocytomas And Gliomas (L.8.01.405)	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Donor Lymphocyte Infusion For Malignancies Treated With An Allogeneic Hematopoietic Stemcell Transplant (L.2.03.402)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Acute Lymphoblastic Leukemia	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Acute Myeloid Leukemia	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Chronic Lymphocytic Leukemiasmall Lymphocytic Lymphoma	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Chronic Myeloid Leukemia	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Cns Embryonal Tumors And Ependymoma	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Epithelial Ovarian Cancer	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Hodgkin Lymphoma	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Miscellaneous Solid Tumors In Adults	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Nonhodgkin Lymphomas	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Plasma Cell Dyscrasias Including Multiple Myeloma And Poems Syndrome	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Primary Amyloidosis Or Waldenstroms Macroglobulinemia	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation For Solid Tumors Of Childhood	covered if criteria are met		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Cell Transplantation In The Treatment Of Germ Cell Tumors	unproven / investigational		payer document
Blue Cross & Blue Shield of Mississippi	Hematopoietic Stemcell Transplantation For Breast Cancer (L.8.01.410)	not covered		payer document
Blue Cross & Blue Shield of Mississippi	Nonmyeloablative Allogeneic Transplants Of Hematopoietic Stemcells For Treatment Of Malignancy (L.8.01.406)	covered if criteria are met		payer document
Blue Cross NC	Cord Blood as a Source of Stem Cells	listed, no stance	Mar 1, 2026	payer document
Blue Cross NC	Hematopoietic Cell Transplantation	listed, no stance	Mar 1, 2026	payer document
Blue Shield of California	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (8.01.15)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Donor Lymphocyte Infusion for Malignancies Treated With an Allogeneic Hematopoietic Cell Transplant (CAM 20303)	listed, no stance	Jan 1, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Cell Transplantation for Breast Cancer (CAM 80127)	listed, no stance	Jul 1, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (CAM 80123)	listed, no stance	Jul 1, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (CAM 80117)	listed, no stance	Jan 1, 2026	payer document
Capital Blue Cross	Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (MP 9.056) Procedure codes	covered if criteria are met	Sep 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma (MP 9.050) Procedure codes	unproven / investigational	May 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma (MP 9.038) Procedure codes	covered if criteria are met	Sep 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (MP 9.048) Procedure codes	unproven / investigational	May 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation for Primary Amyloidosis (MP 9.045) Procedure codes	unproven / investigational	May 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation for Solid Tumors of Childhood (MP 9.054) Procedure Codes	unproven / investigational	Sep 1, 2026	payer document
Capital Blue Cross	Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors (MP 9.052) Procedure Codes	unproven / investigational	Sep 1, 2026	payer document
Centene	Donor Lymphocyte Infusion (CP.MP.101)	covered if criteria are met	Feb 1, 2025	payer document
Cigna	Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost (0261)	listed, no stance	May 15, 2026	payer document
Cigna	Stem Cell Transplantation: Blood Cancers (0533)	covered if criteria are met	Aug 15, 2026	payer document
Cigna	Stem Cell Transplantation: Non-Cancer Disorders (0535)	covered if criteria are met	Jan 15, 2026	payer document
Cigna	Stem Cell Transplantation: Solid Tumors (0534)	covered if criteria are met	Jan 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (SUR703.032) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	May 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (SUR703.043) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Sep 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia (SUR703.037) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Aug 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Autoimmune Diseases (SUR703.036) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Breast Cancer (SUR703.038) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	May 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma (SUR703.039) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Sep 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) (SUR703.029) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	May 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia (SUR703.041) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (SUR703.034) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	May 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias (SUR703.033) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Hodgkin Lymphoma (SUR703.040) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Apr 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (SUR703.035) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Aug 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas (SUR703.031) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	May 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (SUR703.030) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	May 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Primary Systemic Amyloidosis (SUR703.046) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212,	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Solid Tumors of Childhood (SUR703.044) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Jun 15, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia (SUR703.050) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Jan 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors (SUR703.045) CPT Codes 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211,	listed, no stance	Jun 15, 2026	payer document
Regence	Hematopoietic Cell Transplantation for Light-Chain (AL) Amyloidosis or Waldenström Macroglobulinemia (Transplant 45)	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Sep 1, 2026: PA added, Blue Shield of California Promise Health Plan
Apr 1, 2026: conditions changed, Blue Cross and Blue Shield of Illinois
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Jan 1, 2026: conditions changed, Blue Cross and Blue Shield of Illinois
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: PA added, UnitedHealthcare
Jan 1, 2025: PA removed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in IN, NE, VA, WA.

AZ: $785.70 (asc), effective Oct 1, 2026
CO: $103.21 (chp_plus, non-facility), effective Jul 1, 2026
FL: $86.40 (physician, non-facility), effective Jan 1, 2026
IL: $83.94 (practitioner), effective Apr 1, 2024
IN: $98.04 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $56.95 (default, Exempt Physician), effective Aug 1, 2024
KY: $834.37 (asc), effective Jan 1, 2026
LA: $100.73 (professional), effective Jul 1, 2025
MA: $568.49 (asc), effective May 1, 2026
MS: $703.70 (comprehensive, facility), effective Oct 1, 2025
ND: $491.86 (physician, facility), effective Aug 1, 2026
NE: $19.22 (physician, non-facility), effective Jul 1, 2026
NY: $8.08 (ordered_ambulatory), effective Jul 24, 2026
OH: $65.38 (physician), effective Jan 1, 2024
OK: $94.91 (physician, non-facility), effective Jul 1, 2026
TX: $564.62 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $78.21 (medical), effective Jul 1, 2011
VT: $1209.28 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $62.87 (physician, facility), effective Jul 1, 2026
WY: $688.75 (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.

38242 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 38242

Payer coverage policies that name 38242

Recent prior-auth changes

Medicaid fee-for-service

`38242` CPT® code: payer coverage and prior authorization