L8612 Aqueous shunt prosthesisAqueous shunt
23 of 23 payer prior-auth lists that name L8612 require prior authorization or set conditions: Rocky Mountain Health Plans, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| 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 | KanCare | KS | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Kansas Medicaid Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| UnitedHealthcare Community Plan | Minnesota Metro Medicaid | MN | prior auth under conditions | Prior authorization required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500 | Oct 1, 2024 | Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024 |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth under conditions | Prior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed, with a retail purchase or cumulative rental cost of more than $500 | Apr 1, 2025 | Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | New Jersey FamilyCare | NJ | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U |
| 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 | Pennsylvania CHIP | PA | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | 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 under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Rhode Island Medicaid | RI | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | May 1, 2026 | Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Florida | FL | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth under conditions | Prior authorization is required only for the orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care LTSS | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care Medicaid | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023 |
| UnitedHealthcare Community Plan | Wisconsin BadgerCare Plus and Medicaid SSI | WI | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Sep 1, 2026 | Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community |
L8612 appears in 19 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Glaucoma Surgery (0484) | covered if criteria are met | Jul 14, 2026 | payer document |
| Aetna | Glaucoma Surgery (0484) | not covered | Jul 14, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Aqueous Shunts And Stents For Glaucoma | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Prosthetics (L.1.04.401) | covered if criteria are met | payer document | |
| Blue Cross Blue Shield of Massachusetts | Aqueous Shunts and Stents for Glaucoma (223) | listed, no stance | payer document | |
| Blue Shield of California | | Aqueous Shunts and Stents for Glaucoma (9.03.21) | listed, no stance | payer document | |
| Capital Blue Cross | Aqueous Shunts and Stents for Glaucoma (MP 2.149) Procedure codes | covered if criteria are met | Apr 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Aqueous Shunts and Stents for Glaucoma (SUR713.034) CPT Codes 66179, 66180, 66183, 66184, 66185, 66989, 66991, 66999, 0253T, 0449T, | listed, no stance | Jan 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (2026T0443MM) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (CS050.Y) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Idaho Only) (CS050ID.C) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Kansas Only) (CS050KS.03) | listed, no stance | Feb 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Kentucky Only) (CS050KY.09) | listed, no stance | Mar 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Nebraska Only) (CS050NE.Y) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for New Jersey Only) (CS050NJ.V) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for New Mexico Only) (CS050NM.E) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for North Carolina Only) (CSNCT0443.04) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Ohio Only) (CS050OH.D) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Pennsylvania Only) (CS050PA.V) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Glaucoma Surgical Treatments (for Tennessee Only) (CS050TN.V) | listed, no stance | Feb 1, 2026 | payer document |
Prior authorization required or conditional in OH, VA.
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.