Payer policies › CPT 5984059840 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 59840 15 of 16 payer prior-auth lists that name 59840 require prior authorization or set conditions: Humana, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Ohio, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source Humana Humana Healthy Horizons KY prior auth required Jan 1, 2027 please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management 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 Mississippi Medicaid MS prior auth required State exception Jan 1, 2025 Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 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 Exchange OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 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 Michigan Medicaid, Healthy Michigan Plan, CSHCS MI prior auth required 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 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 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
Payer coverage policies that name 59840 59840 appears in 2 coverage policies from Aetna, Capital Blue Cross.
Payer Policy Role in policy Reviewed Document Aetna Immune Globulins for Post-Exposure Prophylaxis (0544) listed, no stance (range 59812-59857) Oct 7, 2026 payer document Capital Blue Cross Gender Affirming Surgery (MP 1.144)Procedure codes covered if criteria are met Apr 1, 2026 payer document
Recent prior-auth changes Jan 1, 2026: PA removed, Molina Healthcare of Michigan Apr 1, 2023: PA removed, Blue Shield of California Promise Health Plan Feb 15, 2023: PA added, Blue Shield of California Promise Health Plan Medicaid fee-for-service Prior authorization required or conditional in KY, NE.
AZ: $1051.19 (asc), effective Oct 1, 2026 CO: $980.00 (chp_plus, non-facility), effective Jul 1, 2026 FL: $156.64 (physician, facility), effective Jan 1, 2026 IL: $792.00 (practitioner), effective Sep 1, 2022 IN: $165.49 (professional, Advanced Practice Nurse (85%), facility), effective Jan 1, 2026 KS: $400.00 (asc, facility), effective Aug 1, 1982 KY: $1696.62 (asc), effective Jan 1, 2026 LA: $265.13 (asc), effective Jul 1, 2012 MA: $1050.01 (asc), effective May 1, 2026 MS: $1339.41 (comprehensive, facility), effective Oct 1, 2025 ND: $1000.16 (physician, facility), effective Aug 1, 2026 NE: $552.00 (asc), effective Jul 1, 2024 NY: $1000.00 (physician_surgery, facility), effective Jul 1, 2026 OH: $178.75 (physician, facility), effective Jan 1, 2024 OK: $1547.86 (asc), effective Jan 1, 2026 TX: $1063.52 (ambulatory_surgical_center_asc_hospital_based_ambulatory_sur, Ambulatory Surgical Center (Asc) / Hospital - Based Ambulatory Surgical Center (Hasc)), effective Jun 1, 2023 VA: $204.49 (medical, facility), effective Jul 1, 2026 VT: $2513.50 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $339.40 (asc), effective Jul 1, 2026 WY: $1431.58 (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.