C1052 Hemostatic agent, gi, topic

Hemostatic agent, gastrointestinal, topical

Medically Unlikely Edits (effective October 1, 2026)

Payer policies and prior authorization for C1052

1 of 1 payer prior-auth lists that name C1052 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)

Payer coverage policies that name C1052

C1052 appears in 1 coverage policy from Premera Blue Cross.

PayerPolicyRole in policyReviewedDocument
Premera Blue CrossNon-covered Experimental/Investigational Serviceslisted, no stanceOct 1, 2026payer document

Medicaid fee-for-service

  • IN: $0.00 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2021
  • KY: $0.00 (asc), effective Jan 1, 2026
  • 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.