84403 CPT® code: payer coverage and prior authorization1 of 1 payer prior-auth lists that name 84403 require prior authorization or set conditions: UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 |
84403 appears in 23 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Erectile Dysfunction and Peyronie's Disease (0007) | covered if criteria are met (range 84402-84403) | Jul 29, 2026 | payer document |
| Aetna | Follitropins and Menotropins (1082) | listed, no stance | Oct 9, 2026 | payer document |
| Aetna | Gonadotropin-Releasing Hormone Analogs and Antagonists (0501) | listed, no stance | Jul 10, 2026 | payer document |
| Aetna | Human Chorionic Gonadotropin (hCG) (1081) | listed, no stance | Oct 8, 2026 | payer document |
| Aetna | Hypoxic Ischemic Encephalopathy (0812) | not covered | Nov 20, 2025 | payer document |
| Aetna | Implantable Hormone Pellets (0345) | listed, no stance | Jul 8, 2026 | payer document |
| Aetna | Infertility (0327) | covered if criteria are met | Jul 16, 2026 | payer document |
| Aetna | Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (0929) | listed, no stance | Jul 17, 2026 | payer document |
| Aetna | Nonstandard Laboratory Test Panels (0499) | listed, no stance | Aug 3, 2026 | payer document |
| Aetna | Salivary Tests (0608) | not covered | Sep 23, 2026 | payer document |
| Aetna | Testosterone Cypionate Injections (1014) | listed, no stance | Jul 13, 2026 | payer document |
| Aetna | Testosterone Enanthate Injection (1015) | listed, no stance | Jul 17, 2026 | payer document |
| Aetna | Testosterone Undecanoate (Aveed) Injection (0528) | listed, no stance | Jul 9, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Pathogen Panel Testing (L.2.04.456) | not covered | payer document | |
| Blue Cross NC | Professional Pathology Billing Requirements AHS – R2169 | listed, no stance (range 84030-84999) | Mar 1, 2024 | payer document |
| Blue Cross NC | Testosterone AHS – G2013 | listed, no stance | Jan 1, 2026 | payer document |
| Centene | covered if criteria are met | Jan 1, 2026 | payer document | |
| Cigna | Infertility Services (0089) | covered if criteria are met | Jun 15, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Sexual Dysfunctions, Assessment and Treatment (MED201.030) CPT Codes 37788, 37790, 54110, 54111, 54112, 54200, 54205, 54230, 54231, | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Testosterone | listed, no stance | May 12, 2026 | payer document |
| Regence | Screening Laboratory Testing (Laboratory 80) | listed, no stance | Dec 1, 2025 | payer document |
| Regence | Testosterone Testing (Laboratory 81) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Infertility Diagnosis, Treatment, and Fertility Preservation (2026T0270NN) | listed, no stance | Jun 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.