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PAYER POLICY CHANGES

54100 Insurance Policy Changes

CPT 54100, in plain terms, covers Surgeon takes a biopsy of the skin of the penis, not the deeper structures. CPT 54100 is referenced in 3 tracked payer policy changes from UnitedHealthcare. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 54100 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 54100 on AAPC

Watch 54100

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REFERENCE DATA

Payers with rules3
Payers requiring prior auth3
  • Anthem BCBS · Effective October 19, 2026

    Prior authorization required

    Anthem local precertification/prior authorization list (Colorado | Anthem Blue Cross and Blue Shield | Commercial)

  • CalViva Health · Effective December 31, 2025

    Prior authorization required

    CalViva Health CMS-0057-F prior authorization requirements

  • Community Health Plan of Imperial Valley · Effective December 31, 2025

    Prior authorization required

    Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does Anthem BCBS require prior authorization for 54100?

Anthem BCBS lists 54100 on Anthem local precertification/prior authorization list (Colorado | Anthem Blue Cross and Blue Shield | Commercial) for commercial plans (list dated October 19, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 54100?

CalViva Health lists 54100 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 54100?

Community Health Plan of Imperial Valley lists 54100 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 54100?

There are 3 tracked policy changes affecting CPT 54100, including updates from UnitedHealthcare. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 54100?

Payers that have issued tracked updates for CPT 54100 include: UnitedHealthcare.

How do I get notified when CPT 54100 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 54100. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 54100?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for 54100

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 54100 in one place.

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RELATED

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