Cigna prior authorization, page 19

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
51721*	Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed	Master Precertification List For Health Care Providers, Pg 47 Original policy
53451*	Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance	Master Precertification List For Health Care Providers, Pg 47 Original policy
53452*	Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance	Master Precertification List For Health Care Providers, Pg 47 Original policy
53865*	Cystourethroscopy with insertion of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate	Master Precertification List For Health Care Providers, Pg 47 Original policy
53899*	Unlisted procedure, urinary system	Master Precertification List For Health Care Providers, Pg 47 Original policy
54125*	Amputation of penis; complete	Master Precertification List For Health Care Providers, Pg 47 Original policy
54161*	Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age	Master Precertification List For Health Care Providers, Pg 47 Original policy
54400*	Insertion of penile prosthesis; non-inflatable (semi-rigid)	Master Precertification List For Health Care Providers, Pg 47 Original policy
54401*	Insertion of penile prosthesis; inflatable (self-contained)	Master Precertification List For Health Care Providers, Pg 47 Original policy
54405*	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir	Master Precertification List For Health Care Providers, Pg 47 Original policy
55875*	Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy	Master Precertification List For Health Care Providers, Pg 47 Original policy
55876*	Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple	Master Precertification List For Health Care Providers, Pg 47 Original policy
55880*	Ablation of malignant prostate tissue, transrectal, with high intensity- focused ultrasound (HIFU), including ultrasound guidance	Master Precertification List For Health Care Providers, Pg 47 Original policy
55881*	Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation	Master Precertification List For Health Care Providers, Pg 47 Original policy
55882*	Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed	Master Precertification List For Health Care Providers, Pg 47 Original policy
55899*	Unlisted procedure, male genital system	Master Precertification List For Health Care Providers, Pg 47 Original policy
55920*	Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application	Master Precertification List For Health Care Providers, Pg 48 Original policy
55970*	Intersex surgery; male to female	Master Precertification List For Health Care Providers, Pg 48 Original policy
55980*	Intersex surgery; female to male	Master Precertification List For Health Care Providers, Pg 48 Original policy
56620*	Vulvectomy simple; partial	Master Precertification List For Health Care Providers, Pg 48 Original policy
56805*	Clitoroplasty for intersex state	Master Precertification List For Health Care Providers, Pg 48 Original policy
57110*	Vaginectomy, complete removal of vaginal wall;	Master Precertification List For Health Care Providers, Pg 48 Original policy
57155*	Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy	Master Precertification List For Health Care Providers, Pg 48 Original policy
57156*	Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy	Master Precertification List For Health Care Providers, Pg 48 Original policy
57291*	Construction of artificial vagina; without graft	Master Precertification List For Health Care Providers, Pg 48 Original policy
57292*	Construction of artificial vagina; with graft	Master Precertification List For Health Care Providers, Pg 48 Original policy
57335*	Vaginoplasty for intersex state	Master Precertification List For Health Care Providers, Pg 48 Original policy
58346*	Insertion of Heyman capsules for clinical brachytherapy	Master Precertification List For Health Care Providers, Pg 48 Original policy
58578*	Unlisted laparoscopy procedure, uterus	Master Precertification List For Health Care Providers, Pg 48 Original policy
58579*	Unlisted hysteroscopy procedure, uterus	Master Precertification List For Health Care Providers, Pg 48 Original policy
58679*	Unlisted laparoscopy procedure, oviduct, ovary	Master Precertification List For Health Care Providers, Pg 48 Original policy
58999*	Unlisted procedure, female genital system (nonobstetrical)	Master Precertification List For Health Care Providers, Pg 48 Original policy
59897*	Unlisted fetal invasive procedure, including ultrasound guidance, when performed	Master Precertification List For Health Care Providers, Pg 48 Original policy
60660*	Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency	Master Precertification List For Health Care Providers, Pg 48 Original policy
60661*	Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency	Master Precertification List For Health Care Providers, Pg 48 Original policy
60699*	Unlisted procedure, endocrine system	Master Precertification List For Health Care Providers, Pg 48 Original policy
61624*	Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord)	Master Precertification List For Health Care Providers, Pg 48 Original policy
61630*	Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous	Master Precertification List For Health Care Providers, Pg 48 Original policy
61635*	Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed	Master Precertification List For Health Care Providers, Pg 48 Original policy
61736*	Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion	Master Precertification List For Health Care Providers, Pg 48 Original policy
61737*	Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s)	Master Precertification List For Health Care Providers, Pg 48 Original policy
61796*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion	Master Precertification List For Health Care Providers, Pg 48 Original policy
61797*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple	Master Precertification List For Health Care Providers, Pg 48 Original policy
61798*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion	Master Precertification List For Health Care Providers, Pg 48 Original policy
61799*	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex	Master Precertification List For Health Care Providers, Pg 48 Original policy
61800*	Application of stereotactic headframe for stereotactic radiosurgery	Master Precertification List For Health Care Providers, Pg 49 Original policy
61863	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array	Master Precertification List For Health Care Providers, Pg 49 Original policy
61867	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array	Master Precertification List For Health Care Providers, Pg 49 Original policy
61886*	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays	Master Precertification List For Health Care Providers, Pg 49 Original policy
61889*	Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s)	Master Precertification List For Health Care Providers, Pg 49 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.