57296 CPT® code: payer coverage and prior authorization35 of 35 payer prior-auth lists that name 57296 require prior authorization or set conditions: 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, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans, UnitedHealthcare, and others.
| 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 | |
| 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 | |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| 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 | |
| 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 California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| 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 under conditions | no PA with cancer dx | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth under conditions | no PA with cancer dx | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth under conditions | no PA with cancer dx | 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 under conditions | no PA with cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Exchange | OH | prior auth under conditions | no PA with cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| 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 under conditions | no PA with cancer dx | Jan 1, 2023 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Jan 1, 2023 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| 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 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth under conditions | no PA with cancer dx | 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 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth under conditions | only with dx F64.A, F64.0, F64.1, F64.2, F64.8, F64.9 | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP) | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, F64.A | Oct 1, 2026 | UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026 |
| 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 |
| UnitedHealthcare Community Plan | Massachusetts OneCare | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Nov 1, 2025 | CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) and OneCare | MA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth under conditions | Prior authorization is only required for these codes with these DX codes. | Jan 1, 2017 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
57296 appears in 9 coverage policies from Aetna, Blue Cross NC, BlueCross BlueShield of South Carolina, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| 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 NC | Sex Trait Modification Procedures For Gender Affirming Care | listed, no stance | Apr 1, 2026 | payer document |
| BlueCross BlueShield of South Carolina | Gender Affirmation Surgery and Hormone Therapy (CAM 373) 57295 | Revise vag graft via vagina | listed, no stance | Jan 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 |
| Premera Blue Cross | Gender Transition/Affirmation Surgery and Related Services (7.01.557) Page | 32 of 59 | ∞ | listed, no stance | Jul 1, 2026 | payer document |
| Regence | Gender Affirming Interventions for Gender Dysphoria (Medicine 153) NOTES | listed, no stance | Nov 1, 2025 | payer document |
| UnitedHealthcare | Gender Dysphoria and Gender Reassignment Surgery (MMP365.14) Male to Female | listed, no stance | Sep 1, 2026 | payer document |
Prior authorization required or conditional in ND, WA, WV.
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.