52005 CPT® code: payer coverage and prior authorization28 of 28 payer prior-auth lists that name 52005 require prior authorization or set conditions: Oxford Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth under conditions | site of care: outpatient hospital; not in AK, GU, IL, MA, PR, RI, TX, UT, VI, WI | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth under conditions | site of care: outpatient hospital | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth under conditions | site of care: outpatient hospital; not in AK, GU, IL, MA, PR, RI, TX, UT, VI, WI | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth under conditions | site of care: outpatient hospital; not in AK, IL, MA, PR, RI, TX, UT, VI, WI | 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 under conditions | site of care: outpatient hospital | 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 under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | site of care: outpatient hospital | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| 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 under conditions | site of care: outpatient hospital, ASC | 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 | Mississippi CHIP | MS | prior auth under conditions | site of care: outpatient hospital | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth under conditions | site of care: outpatient hospital | 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 under conditions | site of care: outpatient hospital | Jul 1, 2026 | Prior authorization requirements for Missouri Medicaid Effective July 1, 2026 |
| UnitedHealthcare Community Plan | New Jersey FamilyCare | NJ | prior auth under conditions | site of care: outpatient hospital | 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 | North Carolina Medicaid | NC | prior auth under conditions | site of care: outpatient hospital, ASC | 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 under conditions | site of care: outpatient hospital, ASC | 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 under conditions | site of care: outpatient hospital | 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 under conditions | site of care: outpatient hospital | 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 under conditions | site of care: outpatient hospital | 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 under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth under conditions | site of care: outpatient hospital | Jul 1, 2020 | 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 under conditions | site of care: outpatient hospital | Jul 1, 2020 | 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 under conditions | site of care: outpatient hospital | Jul 1, 2020 | 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 under conditions | site of care: outpatient hospital | Jul 1, 2020 | 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 under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth under conditions | site of care: outpatient hospital | Oct 1, 2026 | Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023 |
52005 appears in 6 coverage policies from Aetna, Anthem, Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Bupivacaine Liposome (Exparel) (0941) | listed, no stance (range 50010-53899) | Jul 30, 2026 | payer document |
| Aetna | Gender Affirming Surgery (0615) | covered if criteria are met | Sep 8, 2026 | payer document |
| Aetna | Mitomycin Pyelocalyceal Solution (Jelmyto) (0972) | listed, no stance | Aug 13, 2025 | payer document |
| Aetna | Urological Supplies (0533) | listed, no stance | Jul 30, 2026 | payer document |
| Anthem | Outpatient Cystourethroscopy (CG-SURG-51) | covered if criteria are met | May 14, 2026 | payer document |
| Regence | Surgical Site of Care – Hospital Outpatient (Utilization Management 19) | listed, no stance | May 1, 2026 | payer document |
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.