Prior Auth Required

57110 - 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / Service58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
Procedure / Service Description

Service Category Benefit/Description Codes Requiring Authorization Member Program* - 19325, 31599, 17380, 17999 Gender affirming surgery – Female to Male 19303, 19302, 19300, 19318, 53420, 53425, 53430, 54400, 54401, 54405, 54660, 55175, 55180, 15200, 31599, 17380, 17999, All 55899, 55980, 56625, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.