`55873` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 55873

39 of 39 payer prior-auth lists that name 55873 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Humana, Rocky Mountain Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
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 Healthy Horizons	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
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
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
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
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		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 required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth required		Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth required		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 required		Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		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	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		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 required		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 required		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 required		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	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Apr 1, 2022	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth required		Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth required		Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name 55873

55873 appears in 18 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross NC, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Benign Prostatic Hyperplasia (0079)	not covered	Apr 15, 2026	payer document
Aetna	Cryoablation (0100)	covered if criteria are met	Aug 4, 2026	payer document
Anthem	Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver (CG-SURG-61)	covered if criteria are met	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Whole Gland Cryoablation Of Prostate Cancer (L.7.01.449)	listed, no stance		payer document
Blue Cross & Blue Shield of Rhode Island	Whole Gland Cryoablation of Prostate Cancer	covered if criteria are met		payer document
Blue Cross NC	Whole Gland Ablative Treatments of Prostate Cancer	listed, no stance	Nov 1, 2025	payer document
Regence	Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver (Surgery 132)	listed, no stance	Jan 1, 2026	payer document
UnitedHealthcare	Prostate Surgeries and Interventions (2026T0618P)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Prostate Surgeries and Interventions (CS334.H)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Prostate Surgeries and Interventions (for Idaho Only) (CS334ID.C)	listed, no stance	Jul 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 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

Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
Oct 1, 2026: PA removed, Oxford Health Plans
Oct 1, 2026: PA removed, Rocky Mountain Health Plans
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Mar 1, 2025: PA added, Rocky Mountain Health Plans
Mar 1, 2025: PA added, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in WA.

AZ: $6221.54 (asc), effective Oct 1, 2026
CO: $752.82 (chp_plus, non-facility), effective Jul 1, 2026
FL: $535.39 (physician, facility), effective Jan 1, 2026
IL: $739.15 (practitioner), effective Jan 1, 2010
IN: $592.76 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $650.00 (asc, facility), effective Jan 1, 2001
KY: $7221.31 (asc), effective Jan 1, 2026
LA: $4292.64 (professional), effective Jul 1, 2025
MA: $5265.42 (asc), effective May 1, 2026
MS: $5536.66 (comprehensive, facility), effective Oct 1, 2025
ND: $4256.97 (physician, facility), effective Aug 1, 2026
NE: $1662.00 (asc), effective Jul 1, 2024
NY: $583.26 (physician_surgery, facility), effective Jul 1, 2026
OH: $638.63 (physician, facility), effective Jan 1, 2024
OK: $6588.15 (asc), effective Jan 1, 2026
VA: $596.35 (medical, facility), effective Jul 1, 2026
VT: $7350.34 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $500.36 (asc), effective Jul 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.

55873 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 55873

Payer coverage policies that name 55873

Recent prior-auth changes

Medicaid fee-for-service

`55873` CPT® code: payer coverage and prior authorization