CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization guidelines — RMHP Medicare Advantage and Dual-Special-Needs Plans

Lists medical prior authorization requirements and submission instructions for Rocky Mountain Health Plans Medicare Advantage and Dual-Special-Needs Plans; applies to RMHP providers and other requesting clinicians submitting prior authorization requests to RMHP. Services not covered in a member's Evidence of Coverage will not be authorized.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization guidelines — RMHP Medicare Advantage and Dual-Special-Needs Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionIn-network RMHP providers must submit all prior authorization requests via the UnitedHealthcare Provider Portal using One Healthcare ID.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Aug. 1, 2024policy effective date stated

~600+approximate CPT/HCPCS codes listed

portal requiredportal required for in-network

excludedemergency/urgent care excluded

multiple

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multiple service categories

Services Requiring Prior Authorization or Notification

Services requiring prior authorization or notification

Specific services and code ranges requiring prior authorization or notification as listed below. This is a non‑exhaustive excerpt from the full list in this document.

Services and CPT/HCPCS codes listed below require prior authorization or notification as indicated in the policy.

Examples of services requiring prior authorization

Acupuncture — 97810, 97811, 97813, 97814, 0095T, 0098T, 0164T, 23472.
Arthroplasty — 23473, 23474, 23929, 24999, 25999, 26989, 27130, 27132, 27134, 27137, 27138, 27279, 27412, 27445, 27446, 27447, 27486, 27487.
Arthroscopy — 29805–29887 (selected codes listed).
Bariatric surgery — 43644–43888 and related codes (selected codes listed).
Bone growth stimulator / electrical stimulation / ultrasound for fractures — 20957, 20972, 20973.
Breast reconstruction — 11920–11922 and multiple reconstructive codes (selected codes listed).
Cardiology — diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echocardiograms; selected codes include 0572T, 0710T–0713T and EviCore-managed cardiology codes such as 33206–33264, 93451–93462, 93593–93597.
Chemotherapy (injectable) — outpatient injectable chemotherapy requires notification/prior authorization; example codes include 96446 and numerous J‑codes (J9000–J9371, J9360–J9395, J9400, J9600, J9999 and many additional J‑codes listed).
Chiropractic care — 98940–98943.
Cochlear implants — 69711, 69714, 69716, 69717, 69799, 69930.
Continuous glucose monitor — E2102, E2103, A4238, A4239.
Cosmetic and reconstructive procedures — multiple CPT/HCPCS codes (examples: 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21740, 30999, 67901–67911, 69300, 96920–96922, G0429, Q2026).
Diagnostic and therapeutic procedures — many temporary/unlisted/advanced procedure codes (examples: 0046U, 0049U, 0051U, 0052U, 0054U, 0058U, 0059U, 0061U, 0140U–0199U, 0218T, 0251U, 0308U, etc.).
Digestive procedures — example code 39499 and other listed digestive procedure codes (e.g., 0322U, 0394T, 0395T, 0402T, 0449T).
Durable medical equipment (DME) — extensive HCPCS ranges including E‑series and K‑series codes (examples: E0170–E2502, K0001–K0739 and many additional E/K codes listed).
Endocrine procedures — 60659, 60699.
Enteral nutrition supplies — B4149–B4216 and related enteral supply codes.
Gastroenterology — numerous procedure codes including 42699, 42999, 43206, 43210, 43647–43659, 43881–43882, 43999, 44238, 44799, 44979, etc.
Gender dysphoria treatment — selected surgical CPT/HCPCS codes listed (examples include 15771–15776, 15820–15839, 19303, 31899, 53410–53454, 54400–54417, 54699, 55880, 57291–57296, 57426, etc.).
Genetic tests / lab services — extensive CPT/HCPCS ranges including 81162–81471, 81500–81599, many U‑codes (0001U–0538T) and other molecular/genetic codes listed.
Hearing/audio/vision — examples include 0308T, 0378T, 65770, 65785, 66989, 66991, 66999, 67299, 67399, 67599, 67900, 68816, 68841.
Home health care — example codes 99600, G0248–G0250, S9364–S9368.
Hysterectomy — 58578, 58579, 58679.
Infusions and injection — 96379 (infusion), and selected injectable medication codes (e.g., 90283, 90284, J‑codes listed).
Injectable medications — numerous codes including 90283–90399, A9513, J0129, and many J‑codes and Q‑codes; unclassified/temporary codes (C9399, J3490, J3590, C9167/C9168) require prior authorization when used for specific high‑cost therapies.
Medical and surgical supplies — extensive Q‑series supply codes (examples: Q4101–Q4182 listed).
Musculoskeletal procedures — multiple CPT/HCPCS codes (examples: 21029–21089, 21497–21499, 26556, 27599, 29868, 29999, 97750).
Obstetrical procedures — 59072, 59074, 59076, 59897–59899.
Orthognathic surgery — multiple maxillofacial codes (examples: 21100–21299 and related codes).
Orthotics and prosthetics — L‑series codes (examples: L1499, L3000–L3460 and many additional L‑codes).
Potentially unproven procedures — numerous temporary and U‑codes listed (examples: 0014M, 0015M, 0062U–0096U, 0253T, 0321U, 0345T, 0443T, 0470T–0478T, etc.).
Radiation therapy — 32701, 77299, 77373, 77399, 77435, 77499, 77520, 77522–77525, 77605, 77620, 77799, G0339, G0340.
Radiology — wide range of radiology CPT/HCPCS codes require prior authorization; radiology services managed by EviCore (examples include 70450, 72191, 70336, 71250–71275, 71550–71555, 72125–72159, 72191–72198, 73200–73225, 73700–73725, 74150–74185, 75557–75574, 77046–77049, 78414–78496, and many others listed).
Respiratory procedures — example codes 31641, 31647–31661, 31899, 32994, 32999.
Rhinoplasty — 30400–30468 and related codes; Sinuplasty — 31295–31298.
Sleep disorder tests/treatment — example codes 41512, 41530, 41599, 42145, 42160.
Spine surgery — multiple spine codes (examples: 20930, 20931, 20999, 22505, 22533–22534, 22548, 22551–22554, 22558, 22585, 22590, 22595, 22600, 22612, 22614, 22630–22634, 22856–22862).
Transplants — numerous transplant procedure codes (examples: 32850–32856, 33930, 33933, 33935, 33945, 38204–38215, 38230–38243, 47135–47147, 48551–48556, 50300–50380, and others).
Transportation — A0430, A0431, A0435, A0436.
Urological procedures — example code 0499T.
Uterine procedures — example code 58999.
Vein procedures — multiple venous procedure codes (examples: 36465–36483, 36522, 37501, 37700–37799, 38129, 38589, 38999, 61630, 61635, 93702).
Ventricular assist device — 33927, 33928, 33929, 33999, 36299.
Wound care — G0277, G0281, G0329.

Prior authorization required categories

Prior authorization is required for the following categories and associated CPT/HCPCS codes as listed in this section.

Prior authorization is required for the categories and code groups below when billed to RMHP Medicare Advantage and D‑SNP (exceptions for emergency/urgent care apply).

Categories requiring prior authorization (by code examples)

Injectable medications / chemotherapy — extensive J‑code lists and Q‑codes (see policy for full list). Examples include J9000–J9371, J9360–J9400, J9600, J9999, and many additional J‑codes; outpatient injectable chemotherapy requires notification/prior authorization.
Infusions and injection — infusion procedure code 96379 and associated infusion codes require prior authorization.
Home health care — example codes include 99600, G0248–G0250, S9364–S9368.

Code Lists and Selected Codes

Covered CPT/HCPCS — AcupunctureCPTCovered

97810	Acupuncture, initial 15 minutes
97811	Acupuncture, subsequent 15 minutes
97813	Acupuncture with electrical stimulation, initial
97814	Acupuncture with electrical stimulation, subsequent
0095T	Acupuncture, cranial electrostimulation (new code)
0098T	Acupuncture, auricular (new code)

Covered HCPCS/J-codes — Chemotherapy (injectable)HCPCSCovered

J9000-J9371	Antineoplastic and related agents — range included for authorization
J9376-J9400	Additional antineoplastic agents range
J9600	Intravenous infusion, chemo/biological — example code included
J9999	Not otherwise classified chemotherapy agent

Covered HCPCS/Revenue — Durable Medical Equipment (DME)HCPCSCovered

E0170-E2502	Range of E-codes for mobility and DME items included
K0001-K0739	Range of K-codes for DME and prosthetic devices
Various K-codes (K0739, K0800-K0864 etc.)	Additional K-codes listed in full DME section

Covered CPT/HCPCS — Genetic & Molecular TestsmixedCovered

81162-81471	Selected molecular pathology and hereditary cancer panels and related codes
81500-81599	Multigene assays and molecular tests
0001U-0538T (selected molecular/genetic CPT/HCPCS codes)	Large series of specific molecular/genetic test codes listed for authorization (includes 0001U, 0002U, ... up to 0538T)
0095T	Also listed among other procedure-specific codes when applicable

Covered CPT/HCPCS — Selected infusion/injectable codesHCPCSCovered

J9000-J9371	Included in chemotherapy/injectable list where applicable
J9376-J9400	Included additional ranges
J9600	Specific included injectable code
J9999	Included NOS injectable code

Covered Radiology codes managed by EviCoreCPTCovered

70336	CT/other radiology code included
70450	CT head/brain
70460	CT orbit/sinus
70470	CT facial bones
71250-71275	Chest CT series included
71550-71555	MRI chest/other series
72125-72158	Spine MRI series
73700-73725	Extremity MRI series
74150-74178	Abdomen/Pelvis CT/MRI series
77046-77049	Bone density/other specialized radiology

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Submission Instructions, Notifications, and Provider Requirements

Prior Authorization

Submission channels and general rule

In-network RMHP providers must submit all prior authorization requests via the UnitedHealthcare Provider Portal using a One Healthcare ID. Non‑participating providers may fax requests and documentation using the Out-of-network prior authorization request form or email specified addresses. Prior authorization is not required for emergency or urgent care.

In-network: UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID
Non-participating: fax using Out-of-network prior authorization form or email per provider instructions
Emergency/urgent care excluded from prior authorization

Prior Authorization

Cardiology prior authorization process

Cardiology outpatient and office‑based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms require notification/prior authorization. Some cardiology services are managed through EviCore; follow the Provider Portal Cardiology tool or EviCore instructions when directed.

Scope and Key Definitions

Prior authorization — definition

DefinitionPrior authorization is the process where health care providers seek approval before rendering a service, required under UnitedHealthcare policy to allow prospective, concurrent and retrospective care review.

PurposeAllows UnitedHealthcare to perform prospective, concurrent and retrospective review of requested services.

Who must requestRequesting health care providers (in-network and out-of-network) when the service falls under RMHP prior authorization requirements.

ExceptionsEmergency or urgent care services are not subject to prior authorization requirements.

Scope

Plan applicabilityApplies to Rocky Mountain Health Plans Medicare Advantage and Dual-Special-Needs Plans providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization guidelines — RMHP Medicare Advantage and Dual-Special-Needs Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionIn-network RMHP providers must submit all prior authorization requests via the UnitedHealthcare Provider Portal using One Healthcare ID.

SourceLink

On This Page

Hysterectomy — example codes 58578, 58579, 58679.

Medical/surgical supplies — multiple Q‑codes are listed and require prior authorization.

Musculoskeletal / orthotics / prosthetics — musculoskeletal surgical codes and L‑series orthotic codes require prior authorization (examples: 21029–21499, L3000, L3465, L3470, L3480, L3500, L3510, L3520, L3530, L3540, etc.).

Radiology and radiology managed by EviCore — extensive radiology CPT ranges require notification/prior authorization; EviCore‑managed radiology requires notification/prior authorization for participating and non‑participating providers (examples: CT/MRI codes such as 70450, 71250–71275, 71550–71555, 72191, 72192–72198, 73700–73725, 74150–74185, etc.).

Transplants — numerous transplant procedure codes require prior authorization (examples: 32850–32856, 33930, 38204–38215, 47135–47147, 48551–48556, 50300–50380, etc.).

Spine surgery and stimulators — spine surgical codes require prior authorization (examples: 20930, 22505, 22612, 22632–22634, 22856–22862).

Wound care — G0277, G0281, G0329 require prior authorization.

Potentially unproven / unclassified and temporary codes — many U/C/T codes require prior authorization (examples listed in policy such as 0014M, 0015M, 0062U–0096U, 0253T, C9352–C9376, C9762–C9767, etc.).

Submit cardiology requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 800-666-1353

When managed by EviCore, submit via EviCore (877-PRE-AUTH or EviCore website) as directed

Documentation Required

Advance notification and review

Advance notification is required so UnitedHealthcare Health Services can perform prospective, concurrent and retrospective review. Out-of-network providers must request prior authorization for all procedures except emergent or urgent care.

Advance notification enables prospective, concurrent and retrospective care review by UnitedHealthcare Health Services
Out-of-network providers must request prior authorization for all non-emergent/urgent procedures

Prior Authorization

Radiology prior authorization submission instructions

For radiology notification/prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 1-877-PRE-AUTH; providers may also use the EviCore website as directed.

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (Radiology tool tile)
Alternative: call 1-877-PRE-AUTH or submit via EviCore website when applicable

Prior Authorization

Prior authorization required — general

Prior authorization is required for the multiple service categories and specific CPT/HCPCS codes listed in the policy, including injectable medications and infusions, home health care, hysterectomy, medical/surgical supplies, orthotics/prosthetics, radiology, transplants, spine surgery, stimulators, wound care and other specified services.

Examples of listed codes include 96379 (infusions/injection), 90283 (injectable medications), extensive DME, orthotics/prosthetics (e.g., L3000), transplants (e.g., 32850 series), spine surgery codes (e.g., 22533, 22630) and wound care (G0277, G0281, G0329)
Refer to the full policy code lists for all CPT/HCPCS codes requiring prior authorization

Prior Authorization

EviCore-managed radiology requirement

Radiology services managed by EviCore require notification/prior authorization for both participating and non‑participating providers; these services must be submitted through EviCore per the listed CPT/HCPCS codes or via the UnitedHealthcare Provider Portal Radiology tool as directed.

EviCore-managed radiology code examples include 70450 and 72191 (and many others listed under Radiology services managed by EviCore)
Submit via EviCore portal or use the Provider Portal Radiology tool per policy instructions

Documentation Required

Unclassified/temporary codes for specific therapies

Unclassified and temporary codes (for example C9399, J3490, J3590, C9167, C9168) require prior authorization when used to report specified high‑cost drugs or therapies identified in the policy (e.g., Amvuttra, Briumvi, Roctavian, Skyrizi, Vyvgart‑Hytrulo).

When C9399, C9167, C9168, J3490 or J3590 are used to bill for the named therapies, prior authorization is required
Refer to the injectable/medication sections for the specific drugs associated with these unclassified/temporary codes

Effective dateEffective Aug. 1, 2024.

Scope noteLists medical prior authorization requirements for services where RMHP Medicare Advantage and D‑SNP is the primary payer; services not a benefit of the member's Evidence of Coverage will not be authorized.

UpdatesThis list changes periodically; updates are announced in Network News.

EviCore-managed radiology

RequirementRadiology services managed by EviCore require notification/prior authorization for both participating and non‑participating providers.

Submission via UHC Provider PortalFor radiology notification/prior authorization, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) under the Radiology tool tile.

Submission via EviCoreProviders may also log on to the EviCore website to submit requests for radiology services managed by EviCore.

Phone optionProviders can call 1-877-PRE-AUTH for radiology prior authorization assistance.