53899 CPT® code: payer coverage and prior authorization29 of 30 payer prior-auth lists that name 53899 require prior authorization or set conditions: Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Rocky Mountain Health Plans, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2006 | Master Precertification List (For Health Care Providers) |
| Cigna | Other Services | All | prior auth required | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs | |
| Cigna | Other Services | All | prior auth required | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Other Services | |
| HealthSpring | Medicare Advantage | All | prior auth required | Apr 1, 2025 | 2026 Q4 Prior Authorization 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 | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| 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 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 Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| 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 Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| 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 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 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 | 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 | |
| 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 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 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 |
53899 appears in 23 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Capital Blue Cross, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Bupivacaine Liposome (Exparel) (0941) | listed, no stance (range 50010-53899) | Jul 30, 2026 | payer document |
| Anthem | Portable Normothermic Organ Perfusion Systems (TRANS.00039) | unproven / investigational | Aug 13, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Botulinum Toxin (S.5.01.491) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Botulinum Toxin (L.5.01.491) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Focal Treatments For Prostate Cancer | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Microwave Tumor Ablation (A.7.01.133) | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Pelvic Floor Stimulation As A Treatment Of Urinary And Fecal Incontinence | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Radiofrequency Ablation Of Miscellaneous Solid Tumors Excluding Liver Tumors | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Mississippi | Transvaginal And Transurethral Radiofrequency Tissue Remodeling For Urinary Stress Incontinence (L.2.01.426) | unproven / investigational | payer document | |
| Blue Cross & Blue Shield of Rhode Island | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Commercial Products for Urinary Incontinence | covered if criteria are met | Oct 1, 2025 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Medicare Advantage Plans for Urinary Incontinence | listed, no stance | Oct 1, 2025 | payer document |
| Blue Cross Blue Shield of Massachusetts | Gender Affirming Services (Transgender Services) (189) | unproven / investigational | payer document | |
| BlueCross BlueShield of South Carolina | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (CAM 10117) | listed, no stance | Apr 1, 2026 | payer document |
| Capital Blue Cross | Gender Affirming Surgery (MP 1.144) Procedure codes | covered if criteria are met | Apr 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) | Pelvic Floor Stimulation as a Treatment of Urinary or Fecal Incontinence (DME101.037) | listed, no stance | Oct 15, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Radiofrequency Energy Therapy for Stress Urinary Incontinence (SUR710.021) | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Magnetic Resonance Imaging–Guided Focused Ultrasound (7.01.109) | listed, no stance | Sep 7, 2026 | payer document |
| Premera Blue Cross | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (1.01.17) | listed, no stance | May 12, 2026 | payer document |
| Premera Blue Cross | Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia (7.01.181) | listed, no stance | Jul 14, 2026 | payer document |
| Regence | Benign Prostatic Hyperplasia Surgical Treatments (Surgery 210) | listed, no stance | Feb 1, 2026 | payer document |
| Regence | Microwave Tumor Ablation (Surgery 189) | listed, no stance | Dec 1, 2025 | payer document |
| Regence | Pelvic Floor Stimulation or Mechanotransduction as a Treatment of Urinary and Fecal Incontinence (Allied Health 04) | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Urinary and Fecal Incontinence: Diagnosis and Treatment (MMP049.14) when used to report Viveve system | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in FL, VT, WA, WV, WY.
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.