69090 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 69090

2 of 2 payer prior-auth lists that name 69090 require prior authorization or set conditions: Oxford Health Plans, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Oxford Health PlansOxford Health PlansAllprior auth requiredOct 1, 2026Prior Authorization Requirements for Oxford Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Connected (Texas MMP)TXprior auth requiredJan 1, 2015Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U

Payer coverage policies that name 69090

69090 appears in 19 coverage policies from Aetna, Anthem, Blue Shield of California, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaCosmetic Surgery and Procedures (0031)
Thermal therapy (e.g., radiofrequency (ThermiVa and Viveve procedures) and laser), Laviv (azficel-T)		not coveredJun 25, 2026payer document
AnthemCosmetic and Reconstructive Services of the Head and Neck (ANC.00008)not coveredAug 13, 2026payer document
Blue Shield of CaliforniaBSC7.08 | Cosmetic and Reconstructive Procedureslisted, no stancepayer document
Capital Blue CrossCosmetic and Reconstructive Surgery (MP 1.004)
Procedure codes		not coveredSep 1, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Cosmetic and Reconstructive Procedures (SUR716.001)
CPT Codes 11200, 11201, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960,		listed, no stanceJan 1, 2026payer document
Premera Blue CrossNon-covered Services and Procedures
Page | 7 of 30 | ∞		listed, no stanceJun 1, 2026payer document
RegenceCosmetic and Reconstructive Procedures (Surgery 12)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (MP.007.33)listed, no stanceJun 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (CS027.AD)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Idaho Only) (CS027ID.C)
The following codes may be Cosmetic; review is required to determine if considered Cosmetic or		listed, no stanceMay 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Kansas Only) (CS027KS.03)listed, no stanceSep 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Kentucky Only) (CS027KY.13)listed, no stanceAug 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Nebraska Only) (CS027NE.U)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for New Jersey Only) (CS027NJ.W)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for New Mexico Only) (CS027NM.E)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for North Carolina Only) (CSNC.MP.007.10)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Ohio Only) (CS027OH.E)listed, no stanceAug 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Pennsylvania Only) (CS027PA.AD)listed, no stanceJul 1, 2026payer document
UnitedHealthcareCosmetic and Reconstructive Procedures (for Tennessee Only) (CS027TN.AB)listed, no stanceAug 1, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

  • ND: $0.00 (physician), effective Aug 1, 2026
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), 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.