54406 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 54406

12 of 12 payer prior-auth lists that name 54406 require prior authorization or set conditions: Aetna, Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Shield of California, Humana, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Shield of CaliforniaBlue Shield MedicareCAprior auth requiredSep 1, 2026Prior Authorization List for Blue Shield Medicare
Blue Shield of CaliforniaBlue Shield commercialCAprior auth requiredSep 1, 2026Prior Authorization List for Blue Shield
AetnaCommercialAllprior auth requiredAug 1, 2024Participating provider behavioral health precertification list for Aetna
AetnaCommercialAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
AetnaMedicare AdvantageAllprior auth requiredAug 1, 2024Participating provider behavioral health precertification list for Aetna
AetnaMedicare AdvantageAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
Blue Cross and Blue Shield of IllinoisBlue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)ILprior auth requiredJan 1, 2025Procedure Code List, Effective 1/1/2025
Blue Cross and Blue Shield of New MexicoTurquoise Care (New Mexico Medicaid)NMprior auth requiredOct 1, 2026New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
HumanaHumana Healthy HorizonsLAprior auth requiredJan 1, 2027Humana 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
HumanaHumana Healthy HorizonsOKprior auth requiredJan 1, 2027Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
HumanaHumana Puerto Rico MA and Dual Medicare-MedicaidPRprior auth requiredNov 3, 2025Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth under conditionsonly with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890Sep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026

Payer coverage policies that name 54406

54406 appears in 18 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Capital Blue Cross, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaErectile Dysfunction and Peyronie's Disease (0007)covered if criteria are met (range 54400-54417)Jul 29, 2026payer document
AetnaGender Affirming Surgery (0615)covered if criteria are met (range 54400-54417)Sep 8, 2026payer document
Blue Cross & Blue Shield of MississippiProsthetics (L.1.04.401)covered if criteria are metpayer document
Blue Cross NCPenile Prosthesislisted, no stanceNov 1, 2025payer document
Capital Blue CrossGender Affirming Surgery (MP 1.144)
Procedure codes		covered if criteria are metApr 1, 2026payer document
CenteneGender-Affirming Procedures (CP.MP.95)covered if criteria are metJul 1, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Gender Assignment Surgery and Gender Reassignment Surgery with Related Services (SUR717.001)
CPT Codes 11950, 11951, 11952, 11954, 11980, 11981, 11982, 11983, 15780,		listed, no stanceJan 1, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Sexual Dysfunctions, Assessment and Treatment (MED201.030)
CPT Codes 37788, 37790, 54110, 54111, 54112, 54200, 54205, 54230, 54231,		listed, no stanceJan 1, 2026payer document
Premera Blue CrossNon-covered Services and Procedures
Page | 7 of 30 | ∞		listed, no stanceJun 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (2026T0580U)listed, no stanceJul 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (CS145.T)listed, no stanceJul 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (for Kansas Only) (CS145KS.02)listed, no stanceMay 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (for New Jersey Only) (CS145NJ.L)listed, no stanceMay 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (for New Mexico Only) (CS145NM.D)listed, no stanceMay 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (for North Carolina Only) (CSNCT0145.04)listed, no stanceJun 1, 2026payer document
UnitedHealthcareGender Dysphoria Treatment (for Ohio Only) (CS145OH.C)listed, no stanceSep 1, 2024payer document
UnitedHealthcareGender Dysphoria Treatment (for Pennsylvania Only) (CS145PA.P)listed, no stanceMay 1, 2026payer document
UnitedHealthcareGender Dysphoria and Gender Reassignment Surgery (MMP365.14)
Other Ancillary Services		listed, no stanceSep 1, 2026payer document

Recent prior-auth changes

  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of Illinois
  • Jun 1, 2023: PA removed, Blue Shield of California Promise Health Plan
  • Dec 1, 2021: PA added, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, NE, WV.

  • AZ: $1171.31 (asc), effective Oct 1, 2026
  • CO: $566.07 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $516.42 (physician, non-facility), effective Jan 1, 2026
  • IN: $567.36 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
  • KY: $1681.93 (asc), effective Jan 1, 2026
  • LA: $217.00 (asc), effective Jul 1, 2012
  • MA: $1170.42 (asc), effective May 1, 2026
  • ND: $991.50 (physician, facility), effective Aug 1, 2026
  • NE: $637.00 (asc), effective Jul 1, 2024
  • NY: $370.34 (physician_surgery, facility), effective Jul 1, 2026
  • OH: $526.52 (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: $575.23 (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.