`54840` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 54840

27 of 27 payer prior-auth lists that name 54840 require prior authorization or set conditions: Humana, Neighborhood Health Partnership, Oxford Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
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
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
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 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	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	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 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

Payer coverage policies that name 54840

54840 appears in 4 coverage policies from Aetna, Capital Blue Cross, Cigna, Regence.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Infertility (0327)	covered if criteria are met	Jul 16, 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	Infertility Services (0089)	covered if criteria are met	Jun 15, 2025	payer document
Regence	Surgical Site of Care – Hospital Outpatient (Utilization Management 19)	listed, no stance	May 1, 2026	payer document

Recent prior-auth changes

Oct 1, 2026: conditions changed, UnitedHealthcare Community Plan
Aug 1, 2026: conditions changed, UnitedHealthcare
Jul 1, 2026: conditions changed, UnitedHealthcare
Jul 1, 2026: conditions changed, UnitedHealthcare
Jul 1, 2026: conditions changed, UnitedHealthcare
Jul 1, 2026: conditions changed, Neighborhood Health Partnership
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

AZ: $690.65 (asc), effective Oct 1, 2026
CO: $266.69 (chp_plus, non-facility), effective Jul 1, 2026
FL: $232.24 (physician, non-facility), effective Jan 1, 2026
IL: $299.70 (practitioner), effective Jul 1, 2026
IN: $251.15 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $435.00 (asc, facility), effective Aug 1, 1982
KY: $978.05 (asc), effective Jan 1, 2026
LA: $217.00 (asc), effective Jul 1, 2012
MA: $671.25 (asc), effective May 1, 2026
MS: $767.90 (comprehensive, facility), effective Oct 1, 2025
ND: $576.56 (physician, facility), effective Aug 1, 2026
NE: $552.00 (asc), effective Jul 1, 2024
NY: $164.86 (physician_surgery, facility), effective Jul 1, 2026
OH: $261.77 (physician), effective Jan 1, 2000
OK: $892.30 (asc), effective Jan 1, 2026
TX: $652.80 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023
VA: $258.68 (medical), effective Jul 1, 2026
VT: $1623.10 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $308.28 (asc), effective Jul 1, 2026
WY: $924.45 (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.

54840 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 54840

Payer coverage policies that name 54840

Recent prior-auth changes

Medicaid fee-for-service

`54840` CPT® code: payer coverage and prior authorization