`55880` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 55880

47 of 47 payer prior-auth lists that name 55880 require prior authorization or set conditions: Aetna, CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, 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, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2021	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, 2021	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
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)	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 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 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	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
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 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, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
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 Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
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	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
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	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, 2021	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Jan 1, 2021	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 Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
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
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
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth under conditions	only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890	Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name 55880

55880 appears in 11 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Cigna, Premera Blue Cross, Regence.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	High Intensity Focused Ultrasound (0766)	listed, no stance	Nov 13, 2025	payer document
Aetna	Ventricular Assist Devices (0654)	covered if criteria are met	Sep 10, 2026	payer document
Anthem	Ultrasound Ablation for Oncologic Indications (CG-MED-81)	not covered	Nov 6, 2025	payer document
Blue Cross & Blue Shield of Mississippi	Focal Treatments For Prostate Cancer	unproven / investigational		payer document
Blue Cross & Blue Shield of Rhode Island	Focal Treatments for Prostate Cancer	not covered	Jun 17, 2026	payer document
Blue Cross Blue Shield of Massachusetts	Focal Treatments for Prostate Cancer (733)	unproven / investigational		payer document
Blue Cross NC	Focal Treatments for Prostate Cancer	listed, no stance	Nov 1, 2025	payer document
Blue Cross NC	Whole Gland Ablative Treatments of Prostate Cancer	listed, no stance	Nov 1, 2025	payer document
Cigna	High Intensity Focused Ultrasound (HIFU) (0274)	covered if criteria are met	Dec 15, 2025	payer document
Premera Blue Cross	Focal Treatments for Prostate Cancer (8.01.541)	listed, no stance	Apr 13, 2026	payer document
Regence	Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS), and High Intensity Focused Ultrasound (HIFU) Ablation, and Transurethral Ultrasound Ablation (TULSA) (Surgery 139)	listed, no stance	Oct 1, 2025	payer document

Recent prior-auth changes

Jan 1, 2026: PA removed, Humana
Jan 1, 2026: PA removed, Molina Healthcare of Michigan
Mar 1, 2025: PA removed, Rocky Mountain Health Plans
Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

AZ: $4907.31 (asc), effective Oct 1, 2026
CO: $799.92 (chp_plus, non-facility), effective Jul 1, 2026
FL: $683.98 (physician, non-facility), effective Jan 1, 2026
IL: $669.59 (practitioner), effective Apr 1, 2024
IN: $757.85 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026
KS: $1926.37 (asc, facility), effective Jan 1, 2021
KY: $4876.65 (asc), effective Jan 1, 2026
LA: $814.73 (professional), effective Jan 1, 2021
MA: $1753.87 (asc), effective May 1, 2026
ND: $2874.79 (physician, facility), effective Aug 1, 2026
NE: $1111.50 (physician, non-facility), effective Jul 1, 2026
NY: $522.85 (physician_surgery, facility), effective Jul 1, 2026
OH: $731.05 (physician), effective Jan 1, 2021
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.

55880 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 55880

Payer coverage policies that name 55880

Recent prior-auth changes

Medicaid fee-for-service

`55880` CPT® code: payer coverage and prior authorization