Payer policies › CPT 5386553865 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 53865 26 of 26 payer prior-auth lists that name 53865 require prior authorization or set conditions: CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky).
Payer Plan State Prior auth Conditions Since Source Cigna ACA/IFP All prior auth required May be delegated to eviCore for some clients Jan 1, 2025 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required May be delegated to eviCore for some clients Jan 1, 2025 Master Precertification List (For Health Care Providers) Cigna Other Services All prior auth required Mar 7, 2026 Cigna Commercial Prior Authorization Procedure Code List: Other Services Cigna Other Services All prior auth required Mar 7, 2026 Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs CarePlus Health Plans CarePlus Health Plans FL prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana D-SNP (FL) FL prior auth required Jan 1, 2027 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois Prior Authorization and Notification List Humana Humana D-SNP (IN) IN prior auth required Jan 1, 2027 *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List Humana Humana D-SNP (MI) MI prior auth required Jan 1, 2027 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List Humana Humana D-SNP (SC) SC prior auth required Jan 1, 2027 Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List Humana Humana D-SNP (VA) VA prior auth required Jan 1, 2027 Virginia Prior Authorization and Notification List Humana Humana MA and D-SNP All prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List 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 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 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 California Medicaid CA prior auth required Apr 1, 2026 Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 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 Illinois Medicaid IL prior auth required Jan 1, 2025 Molina Healthcare of Illinois Codification Grid Q3 2026 Molina Healthcare of Michigan Medicaid MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of New Mexico Medicaid NM prior auth required Jan 1, 2025 New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 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 Jan 1, 2025 Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 Molina Healthcare of Texas Exchange TX prior auth required Replaces code C9769 Jan 1, 2025 Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 Molina Healthcare of Utah Medicaid UT prior auth required Jan 1, 2025 Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 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
Payer coverage policies that name 53865 53865 appears in 20 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, BlueCross BlueShield of South Carolina, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Benign Prostatic Hyperplasia (0079) covered if criteria are met Apr 15, 2026 payer document Aetna Bupivacaine Liposome (Exparel) (0941) listed, no stance (range 50010-53899) Jul 30, 2026 payer document Blue Cross & Blue Shield of Mississippi Temporarily Implanted Nitinol Device Itind For Benign Prostatic Hyperplasia (A.7.01.175) unproven / investigational payer document Blue Cross & Blue Shield of Rhode Island Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia not covered Feb 18, 2026 payer document BlueCross BlueShield of South Carolina Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia (CAM 701175) listed, no stance Mar 1, 2026 payer document Cigna Benign Prostatic Hyperplasia (BPH) Surgical Treatments (0159) not covered Sep 15, 2026 payer document Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia (MED201.025) listed, no stance Apr 1, 2026 payer document Premera Blue Cross Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia (7.01.175) listed, no stance Feb 9, 2026 payer document Regence Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis (Surgery 230) listed, no stance Dec 1, 2025 payer document UnitedHealthcare Prostate Surgeries and Interventions (CS334.H) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (2026T0618P) listed, no stance Jun 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Kansas Only) (CS334KS.02) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Kentucky Only) (CS334KY.12) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Nebraska Only) (CS334NE.I) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for New Jersey Only) (CS334NJ.G) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for New Mexico Only) (CS334NM.D) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for North Carolina Only) (CSNCT0705.09) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Ohio Only) (CS334OH.E) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Pennsylvania Only) (CS334PA.H) listed, no stance Jul 1, 2026 payer document UnitedHealthcare Prostate Surgeries and Interventions (for Tennessee Only) (CS334TN.H) listed, no stance Jul 1, 2026 payer document
Recent prior-auth changes Jan 1, 2026: PA added, Molina Healthcare of Michigan Apr 1, 2025: PA added, Molina Complete Care (Virginia) Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Illinois Jan 1, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Texas Medicaid fee-for-service Prior authorization required or conditional in IN.
AZ: $6405.66 (asc), effective Oct 1, 2026 CO: $2343.62 (health_first_colorado), effective Jul 1, 2026 IL: $111.71 (practitioner), effective Jan 1, 2025 KY: $7549.79 (asc), effective Jan 1, 2026 LA: $2268.36 (professional), effective Jan 1, 2025 MA: $6293.53 (asc), effective May 1, 2026 MS: $5923.32 (comprehensive, facility), effective Oct 1, 2025 ND: $4450.61 (physician, facility), effective Aug 1, 2026 OH: $122.76 (physician, facility), effective Jan 1, 2025 VA: $126.16 (medical, facility), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $4186.41 (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.