Payer policies › CPT 5345053450 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 53450 4 of 4 payer prior-auth lists that name 53450 require prior authorization or set conditions: Humana, Neighborhood Health Partnership, UnitedHealthcare.
Payer Plan State Prior auth Conditions Since Source Humana Humana Healthy Horizons LA prior auth required Jan 1, 2027 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate Humana Humana Puerto Rico MA and Dual Medicare-Medicaid PR prior auth required Nov 3, 2025 Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth under conditions site of care: outpatient hospital; not in AK, IL, GU, MA, PR, RI, TX, UT, VI, WI Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 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
Payer coverage policies that name 53450 53450 appears in 2 coverage policies from Aetna, Cigna.
Payer Policy Role in policy Reviewed Document Aetna Bupivacaine Liposome (Exparel) (0941) listed, no stance (range 50010-53899) Jul 30, 2026 payer document Cigna Gender Dysphoria Treatment (0266) covered if criteria are met Sep 15, 2026 payer document
Recent prior-auth changes 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 Aug 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, Neighborhood Health Partnership Jul 1, 2026: conditions changed, UnitedHealthcare Jul 1, 2026: conditions changed, UnitedHealthcare Medicaid fee-for-service Prior authorization required or conditional in WA.
AZ: $1171.31 (asc), effective Oct 1, 2026 CO: $324.63 (chp_plus, non-facility), effective Jul 1, 2026 FL: $294.84 (physician, non-facility), effective Jan 1, 2026 IL: $279.59 (practitioner), effective Apr 1, 2024 IN: $319.26 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $350.00 (asc, facility), effective Aug 1, 1982 KY: $1681.93 (asc), effective Jan 1, 2026 LA: $182.30 (asc), effective Jul 1, 2012 MA: $1170.42 (asc), effective May 1, 2026 MS: $1324.25 (comprehensive, facility), effective Oct 1, 2025 ND: $991.50 (physician, facility), effective Aug 1, 2026 NE: $637.00 (asc), effective Jul 1, 2024 NY: $205.89 (physician_surgery, facility), effective Jul 1, 2026 OH: $257.05 (physician), effective Jan 1, 2024 OK: $1534.46 (asc), effective Jan 1, 2026 TX: $1142.90 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $328.41 (medical), effective Jul 1, 2026 VT: $2737.01 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $339.40 (asc), effective Jul 1, 2026 WY: $1558.88 (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.