57107 CPT® code: payer coverage and prior authorization13 of 13 payer prior-auth lists that name 57107 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, Blue Shield of California Promise Health Plan, Humana, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare | |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | Sep 1, 2026 | Prior Authorization List for Blue Shield | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Aetna | Commercial | All | prior auth required | Aug 1, 2024 | Participating provider behavioral health precertification list for Aetna | |
| 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® | |
| Aetna | Medicare Advantage | All | prior auth required | Aug 1, 2024 | Participating provider behavioral health precertification list for Aetna | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Oct 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Oct 1, 2026 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 | |
| Humana | Humana Healthy Horizons | LA | prior auth required | Jan 1, 2027 | Humana 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 | |
| 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 | |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
57107 appears in 5 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Acupuncture and Dry Needling (0135) | listed, no stance (range 56405-58999) | Mar 25, 2026 | payer document |
| Aetna | Urological Supplies (0533) | listed, no stance (range 56405-58999) | Jul 30, 2026 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Gender Affirming Care Medicare Advantage Plans and Commercial Products | listed, no stance | Apr 1, 2026 | payer document |
| Centene | Gender-Affirming Procedures (CP.MP.95) | covered if criteria are met | Jul 1, 2026 | payer 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 stance | Jan 1, 2026 | payer document |
Prior authorization required or conditional in WA.
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.