Cigna prior authorization, page 7

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
15879*	Suction assisted lipectomy; lower extremity	Master Precertification List For Health Care Providers, Pg 20 Original policy
17106*	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm	Master Precertification List For Health Care Providers, Pg 20 Original policy
17107*	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm	Master Precertification List For Health Care Providers, Pg 20 Original policy
17108*	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm	Master Precertification List For Health Care Providers, Pg 20 Original policy
17999*	Unlisted procedure, skin, mucous membrane and subcutaneous tissue	Master Precertification List For Health Care Providers, Pg 20 Original policy
19294*	Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy	Master Precertification List For Health Care Providers, Pg 20 Original policy
19296*	Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy	Master Precertification List For Health Care Providers, Pg 20 Original policy
19297*	Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy	Master Precertification List For Health Care Providers, Pg 20 Original policy
19298*	Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance	Master Precertification List For Health Care Providers, Pg 20 Original policy
19300*	Mastectomy for gynecomastia	Master Precertification List For Health Care Providers, Pg 20 Original policy
19316*	Mastopexy	Master Precertification List For Health Care Providers, Pg 20 Original policy
19318*	Breast reduction	Master Precertification List For Health Care Providers, Pg 20 Original policy
19325*	Breast augmentation with implant	Master Precertification List For Health Care Providers, Pg 20 Original policy
19328*	Removal of intact breast implant	Master Precertification List For Health Care Providers, Pg 20 Original policy
19330*	Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)	Master Precertification List For Health Care Providers, Pg 20 Original policy
19340*	Insertion of breast implant on same day of mastectomy (ie, immediate)	Master Precertification List For Health Care Providers, Pg 20 Original policy
19342*	Insertion or replacement of breast implant on separate day from mastectomy	Master Precertification List For Health Care Providers, Pg 20 Original policy
19350*	Nipple/areola reconstruction	Master Precertification List For Health Care Providers, Pg 20 Original policy
19355*	Correction of inverted nipples	Master Precertification List For Health Care Providers, Pg 20 Original policy
19357*	Tissue expander placement in breast reconstruction, including subsequent expansion(s)	Master Precertification List For Health Care Providers, Pg 20 Original policy
19370*	Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy	Master Precertification List For Health Care Providers, Pg 21 Original policy
19371*	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents	Master Precertification List For Health Care Providers, Pg 21 Original policy
19380*	Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant- based reconstruction)	Master Precertification List For Health Care Providers, Pg 21 Original policy
19499*	Unlisted procedure, breast	Master Precertification List For Health Care Providers, Pg 21 Original policy
20527	Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)	Master Precertification List For Health Care Providers, Pg 21 Original policy
20910*	Cartilage graft; costochondral	Master Precertification List For Health Care Providers, Pg 21 Original policy
20912*	Cartilage graft; nasal septum	Master Precertification List For Health Care Providers, Pg 21 Original policy
20930*	Allograft, morselized, or placement of osteopromotive material, for spine surgery only	Master Precertification List For Health Care Providers, Pg 21 Original policy
20931*	Allograft, structural, for spine surgery only	Master Precertification List For Health Care Providers, Pg 21 Original policy
20936*	Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision	Master Precertification List For Health Care Providers, Pg 21 Original policy
20937*	Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision)	Master Precertification List For Health Care Providers, Pg 21 Original policy
20938*	Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision)	Master Precertification List For Health Care Providers, Pg 21 Original policy
20939*	Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision	Master Precertification List For Health Care Providers, Pg 21 Original policy
20975*	Electrical stimulation to aid bone healing; invasive (operative)	Master Precertification List For Health Care Providers, Pg 21 Original policy
20999*	Unlisted procedure, musculoskeletal system, general	Master Precertification List For Health Care Providers, Pg 21 Original policy
21025*	Excision of bone (eg, for osteomyelitis or bone abscess); mandible	Master Precertification List For Health Care Providers, Pg 21 Original policy
21050*	Condylectomy, temporomandibular joint	Master Precertification List For Health Care Providers, Pg 21 Original policy
21060*	Meniscectomy, partial or complete, temporomandibular joint	Master Precertification List For Health Care Providers, Pg 21 Original policy
21073*	Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)	Master Precertification List For Health Care Providers, Pg 21 Original policy
21079	Impression and custom preparation; interim obturator prosthesis	Master Precertification List For Health Care Providers, Pg 21 Original policy
21080	Impression and custom preparation; definitive obturator prosthesis	Master Precertification List For Health Care Providers, Pg 21 Original policy
21081	Impression and custom preparation; mandibular resection prosthesis	Master Precertification List For Health Care Providers, Pg 21 Original policy
21082	Impression and custom preparation; palatal augmentation prosthesis	Master Precertification List For Health Care Providers, Pg 21 Original policy
21085*	Impression and custom preparation; oral surgical splint	Master Precertification List For Health Care Providers, Pg 21 Original policy
21088*	Impression and custom preparation; facial prosthesis	Master Precertification List For Health Care Providers, Pg 21 Original policy
21089*	Unlisted maxillofacial prosthetic procedure	Master Precertification List For Health Care Providers, Pg 21 Original policy
21110*	Application of interdental fixation device for conditions other than fracture or dislocation, includes removal	Master Precertification List For Health Care Providers, Pg 21 Original policy
21120*	Genioplasty; augmentation (autograft, allograft, prosthetic material)	Master Precertification List For Health Care Providers, Pg 21 Original policy
21121*	Genioplasty; sliding osteotomy, single piece	Master Precertification List For Health Care Providers, Pg 21 Original policy
21122*	Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)	Master Precertification List For Health Care Providers, Pg 21 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.