CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Pennsylvania CHIP Medicaid

Defines prior authorization requirements and submission methods for participating providers in UnitedHealthcare Community Plan for Pennsylvania CHIP, covering inpatient and outpatient services and listing codes that require prior authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 800-600-9007 or fax 877-310-3826.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comonline portal

800-600-9007phone

877-310-3826fax

$500DME threshold

numerouscodes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services Requiring Prior Authorization

inv-01: Prior authorization coverage criteria

Services that require prior authorization include, but are not limited to, the following categories and codes:

Covered when the service falls into one of the listed categories and the applicable CPT/HCPCS code is included in the document's prior authorization lists.

Surgical/Procedural

Abortion procedures (CPT 59840–59857) — prior authorization required.
Bariatric surgery (examples: CPT 43644–43846, 43770) — prior authorization required.
Breast reconstruction and related procedures (examples: CPT 19328, 19330, 19340, 19361) — prior authorization required.

Behavioral health

Behavioral health services — prior authorization required; providers should call the number on the back of the member's ID card for specific codes requiring prior authorization.

Cancer supportive care / injectable medications

Injectable colony-stimulating factors, bone‑modifying agents, erythropoiesis‑stimulating agents and other cancer supportive care drugs (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J0897, J0885) — prior authorization required; note prior authorization is required when administered in an outpatient setting for a cancer diagnosis.

Cardiology / Cardiovascular

Outpatient and office‑based diagnostic catheterizations, electrophysiology implants and stress echos (examples: CPT 37220, 37221, 37224, 37225, 37230, 37231, 93580) — prior authorization required.

inv-02: Prior authorization requirements (examples)

Selective services require prior authorization; examples and submission instructions are provided.

ANY of the following

Inpatient video cerebral seizure monitoring (examples: CPT 95700, 95711–95718) — prior authorization required for inpatient services; outpatient EEG does not require prior authorization.
Injectable chemotherapy drugs administered in an outpatient setting (J9000–J9999 and specified J‑codes such as J0640, J0641, J0642, J1950) — prior authorization required. Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Submission instructions: please submit requests online using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).

inv-03: Prior authorization requirements (listed codes)

Categories and codes that require prior authorization as listed in this section.

DME / Enteral / Home nutrition

In‑home enteral nutrition and related DME items (examples: B4034, B4035, B4036, B4100–B4161 series) — prior authorization required.
DME listed in document require prior authorization when retail purchase or cumulative rental cost exceeds $500.

Selected procedures and surgical codes

Femoroacetabular impingement (FAI) (example: CPT 29916) — prior authorization required.
Functional endoscopic sinus surgery (FESS) (examples: CPT 31240, 31253–31259, 31267, 31276, 31287, 31288) — prior authorization required.

inv-04: Coverage — none specified

No explicit coverage criteria provided in this section.

This fragment contains placeholder entries and J‑code listings without specific coverage criteria; no discrete coverage rules are specified in this excerpt.

inv-05: Informational listing — no criteria

No explicit coverage criteria provided in this excerpt; the list is informational and indicates which codes are tied to prior authorization.

Lists of injectable medications and HCPCS/CPT codes (examples include J1290, J2840, J7190, J7211, J0879 and many others) are presented for informational purposes; specific prior authorization instructions are provided elsewhere in the document.

inv-06: Prior authorization requirements — surgical procedures

Joint replacement and orthognathic surgery procedures require prior authorization when performed in listed facility types.

Joint replacement procedures

Total hip and knee and related joint replacement CPT codes (examples: 23470, 23472–23474, 24360–24371, 27120–27138, 27412, 27446–27447, 27486–27487, 29866–29868, J7330, S2112) — prior authorization required when performed in acute care hospitals, acute inpatient rehabilitation, critical access hospitals, or long‑term acute care hospitals.

Orthognathic surgery

Orthognathic surgery (examples: CPT 21121, 21123, 21125, 21127, 21141, 21299) — prior authorization required when performed in acute care hospitals, acute inpatient rehabilitation, critical access hospitals, or long‑term acute care hospitals.

inv-07: Prior authorization requirements — air ambulance

Non-emergent air ambulance transport requires prior authorization.

Non‑emergent air ambulance transport (examples: HCPCS A0430, A0431, A0435, A0436) — prior authorization required.

inv-08: Prior authorization requirements — orthotics and prosthetics

Orthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost is greater than $500.

Orthotics and prosthetics HCPCS L‑codes listed in the document (examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, etc.) — prior authorization required only if retail purchase or cumulative rental cost exceeds $500.

inv-09: Orthotics/prosthetics prior authorization criteria

Prior authorization requirement and applicable codes

Cost threshold rule: Retail purchase or cumulative rental cost > $500 for listed orthotics/prosthetics HCPCS L‑codes — prior authorization required.> 500

Applies to the orthotics/prosthetics HCPCS codes enumerated in the document.

inv-10: Prior authorization/notification statements (partial)

Partial statements about authorization requirements for specific services and radiology prior authorization process.

ANY of the following

Radiology — advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) — prior authorization or notification required; care providers must notify prior to scheduling and may call 866‑889‑8054 or submit requests via UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Radiology Prior Authorization and Notification Program.
Pediatric day services (PDHC) (example: T1024) — prior authorization required.
Private duty nursing (examples: T1000, T1002, T1003) — prior authorization required.
Potentially unproven services (examples: 33289, C2624) — prior authorization required.

inv-11: Prior authorization requirements (listed codes)

Prior authorization is required as indicated for the following categories and codes.

ANY of the following

Site‑of‑service outpatient hospital CPT codes for various urologic and related procedures (examples in document: 52276, 52287, 52320, 52344, 50590, 52000, 52005, 52204, etc.) — prior authorization required as indicated.
Spinal surgery and neurosurgical CPT codes (examples listed in document) — prior authorization required.
Implantation of neurostimulators and devices that send electrical impulses (examples: E0747–E0760, CPT codes 43648, 61863–61868, 63650, 63655, 64553, etc.) — prior authorization required.
CAR T‑cell, gene therapy and transplant services (codes and Q/C procedure codes listed) — prior authorization and transplant case management notification required; contact UnitedHealthcare Community and State Transplant Case Management Team as indicated.

inv-12: Prior authorization stance

Prior authorization requirements and instructions for listed services:

ANY of the following

Code 38232 (bone marrow harvesting) — prior authorization required only for an oncology diagnosis (special note).
Unclassified drug/product codes C9399, J3490, J3590 — prior authorization will be required for specified products (examples provided in document such as Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona).
Ventricular assist devices (VAD) — prior authorization required; providers should call the notification number on the member's ID card and fax the form to the Optum VAD Case Management Team (fax 855‑282‑8929).
Wound vacuum therapy (example: E2402) — prior authorization required.

Codes and Code Groups Mentioned

Surgical/procedural codes requiring prior authorizationCPTCovered

59840-59857	Abortion-related CPT codes indicated in list
43644-43846,43645,43659,43770	Bariatric surgery CPT codes listed
19325-19371,19330,19340,19361-19370	Breast reconstruction and mastectomy-related CPT codes listed

Medication HCPCS/J-codes requiring prior authorizationHCPCSCovered

J1442,J1447,J1448,J2506,Q5101,Q5108,Q5110,Q5111,Q5120,Q5122,Q5125,J1453,J1454,J1456,J1627,J1449,J2820,J0885,J0897

Injectable antiemetics, colony-stimulating factors, trilaciclib, bone-modifying agents and erythropoiesis-stimulating agents requiring prior authorization

Cardiovascular CPT/ICD-10 codesmixedCovered

37220,37221,37224,37225,37230,37231,93580	Endovascular/cardiovascular CPT codes listed
I70., I72., I74., I75., I77., T82., T74., S81., S91.*	ICD-10 diagnosis codes referenced in cardiovascular section

Cardiovascular / vascular diagnosis codesICD-10

I70.739	Listed diagnosis code in cardiovascular section
I70.741	Listed diagnosis code in cardiovascular section
I72.3	Listed diagnosis code
I77.2	Listed diagnosis code

Oncology / skin cancer ICD-10 mappingsICD-10

C43.0	Melanoma ICD-10 mapping examples
C44.01	Skin cancer ICD-10 mapping examples

Reconstructive procedure CPT codesCPT

21230	Reconstructive procedure CPT
21235	Reconstructive procedure CPT
21256	Reconstructive procedure CPT

ICD-10 / internal mapping entriesICD-10

C44.212	ICD-10 code referenced in mapping/list
C44.219	ICD-10 code referenced in mapping/list
C4A.0	Listed under cosmetic and reconstructive section

Selected HCPCS/CPT codesmixedCovered

E0471	Example DME HCPCS code listed for prior authorization
B4100	Enteral nutrition code listed with prior authorization
31240	CPT for FESS listed with prior authorization

Genetic and molecular testing codesCPT | HCPCS | mixed

0018U	Genetic/molecular testing (example)
0022U	Genetic/molecular testing (example)
81163	Genetic testing code included in list

Home health and hospice codesHCPCS | mixed

G0156	Home health services - example
T2045	Hospice - example

Injectable medication J-codesHCPCS

J3262	Actemra®
J1411	Hemgenix
J1439	Injectafer®

HCPCS J-codes mentionedHCPCS

J1290

Referenced with Kalbitor® and Kanuma® in multiple entries

Injectable HCPCS/CPT codes (partial)mixed

J1290	Kanuma
J2840	Koate
J7190	NovoSeven RT
J3358	Stelara
J2326	Spinraza
S0013	Spravato

Examples of injectable and Q-code groupsHCPCS

J1442	White blood cell colony stimulating factor (example)
J1447	White blood cell colony stimulating factor (example)
J1448	White blood cell colony stimulating factor (example)
J2506	White blood cell colony stimulating factor (example)
Q5101	Q-code listed
Q5108	Q-code listed
Q5110	Q-code listed
Q5111	Q-code listed

Sample L-codes listedHCPCS

L0112	Orthotics/prosthetics HCPCS L-code listed
L0170	Orthotics/prosthetics HCPCS L-code listed
L0456	Orthotics/prosthetics HCPCS L-code listed
L0462	Orthotics/prosthetics HCPCS L-code listed
L0464	Orthotics/prosthetics HCPCS L-code listed
L0480	Orthotics/prosthetics HCPCS L-code listed
L0482	Orthotics/prosthetics HCPCS L-code listed
L0484	Orthotics/prosthetics HCPCS L-code listed
L0486	Orthotics/prosthetics HCPCS L-code listed
L0624	Orthotics/prosthetics HCPCS L-code listed

Sample HCPCS/CPT codes presentmixed

L6692	HCPCS code listed in orthotics/prosthetics group
L6713	HCPCS code listed in orthotics/prosthetics group
L6880	HCPCS code listed in orthotics/prosthetics group
G0260	CPT/HCPCS code appearing at end of window
77520	Proton beam therapy
T1024	Pediatric day services (PDHC)

Selected CPT codes by service areaCPT

64721	Carpal tunnel surgery
66821	Cataract surgery
45380	Colonoscopy-related code

Arthroscopy and related procedures (sample from list)CPT

29806
29807
29819
29822
29823
29824

Listed CPT/HCPCS codesmixed

0537T	T-cell therapy procedure code (as listed)
0538T	T-cell therapy procedure code (as listed)
0539T	T-cell therapy procedure code (as listed)
0540T	T-cell therapy procedure code (as listed)
Q2041	HCPCS Q-code listed for therapy
Q2042	HCPCS Q-code listed for therapy
Q2053	HCPCS Q-code listed for therapy
Q2054	HCPCS Q-code listed for therapy
Q2055	HCPCS Q-code listed for therapy
Q2056	HCPCS Q-code listed for therapy

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inv-32: Prior authorization required for outpatient administration

ScopeColony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.

Example codesJ1449, J1442, Q5110, Q5125, J2506 (listed colony-stimulating factor and related J/Q codes).

SubmissionRequests must be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

What Providers Must Do

Prior Authorization

How to obtain prior authorization

To request prior authorization, submit online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com → UnitedHealthcare Provider Portal → Prior Authorization and Notification). You may also call 800-600-9007 or 866-889-8054 (as noted for specialty programs) or fax requests to 877-310-3826. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for non-emergent services.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone: 800-600-9007 (general) or 866-889-8054 (cardiology, radiology and select programs).
Fax: 877-310-3826.
Emergency/urgent care: prior authorization not required.

Prior Authorization

Service-specific prior authorization requirements

Prior authorization is required for many service-specific categories. Providers must obtain authorization before scheduling or delivering the listed services except where noted (for example, outpatient EEGs do not require prior authorization; inpatient video seizure monitoring does). Submit requests via the Provider Portal or call the phone numbers above.

Key Definitions and Thresholds

inv-71: Definition — Prior authorization

DefinitionPrior authorization is a requirement to obtain approval from the health plan before performing certain procedures or services.

Emergency/urgent carePrior authorization is not required for emergency or urgent care.

Out‑of‑network providersOut‑of‑network physicians, facilities and other providers must request prior authorization for all procedures and services except emergent or urgent care.

inv-72: Cancer supportive care injectable medications

Included drug groupsCancer supportive care injectable medications include colony‑stimulating factors, antiemetics, trilaciclib, bone‑modifying agents and erythropoiesis‑stimulating agents listed by J/HCPCS codes.

Example J/Q codes

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug. 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or by phone 800-600-9007 or fax 877-310-3826.

SourceLink

On This Page

Various specified surgical/procedural CPT/HCPCS codes listed (see document lists) — prior authorization required.

Experimental / investigational / linked services

Items marked experimental/investigational or linked services (examples shown in list) — prior authorization required.

Prostate procedures (examples: CPT 37243, 52441, 52442, 53850, 53852, 55866, 55873, 55874) — prior authorization required.

Certain rhinoplasty/septoplasty and sinuplasty procedures — prior authorization required (see document).

Vein procedures (examples: CPT 36468, 36473, 36475, 36478, 37700, 37718, 37722, 37765, etc.) — prior authorization required.

inv-33: DME purchase/rental cost threshold

Threshold amount$500 retail purchase or cumulative rental cost

Applies toDurable medical equipment (DME) codes listed in the DME section (e.g., A9279, E0471, E0465).

ConditionPrior authorization required only when the retail purchase or cumulative rental cost exceeds $500 for the listed codes.

inv-34: Orthotics/Prosthetics prior auth cost threshold

Threshold amount$500 retail purchase or cumulative rental cost

Applies toOrthotics and prosthetics HCPCS L‑codes listed throughout the orthotics/prosthetics section (examples: L0112, L0170, L0456, L0462, L0480).

Facility contextsThreshold note appears with L‑codes for acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long‑term acute care hospitals.

inv-35: Prior authorization cost threshold

General ruleRetail purchase or cumulative rental cost greater than $500 requires prior authorization for the listed orthotics/prosthetics and DME items.

Where statedThis cost threshold is explicitly noted in the Orthotics and Prosthetics and DME sections of the document.

ExamplesApplies to listed L‑codes and DME codes where the 'retail purchase or cumulative rental cost of more than $500' language appears.

Abortion (selected CPTs: 59840–59857, 59850–59851).
Bariatric surgery (examples: 43644, 43645, 43659, 43770, 43775, 43842–43846).
Behavioral health services — call number on member ID for network referral and authorization.
Bone growth stimulators (20975, 20979).
BRCA genetic testing (81162, 81433, 81212, 81216, 81432) — notification/prior authorization required for BRCA before sequencing.
Breast reconstruction (e.g., 19328, 19330, 19340–19361) — prior authorization required.
Cancer supportive care — selected colony-stimulating factors and bone-modifying agents require prior authorization (see Injectable medications).
Cardiology — outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echos require prior authorization (see Cardiology PA resources).
Seizure monitoring — inpatient video cerebral seizure monitoring requires prior authorization (e.g., 95700, 95711–95718).
Chemotherapy — injectable chemotherapy drugs administered in an outpatient setting require prior authorization (J9000–J9999, J0640–J0642, J1950, Q-codes, miscellaneous HCPCS).
Cochlear and other auditory implants (e.g., 69710, 69714, 69930, L8614, L8619, L8690–L8692, L8691).
Continuous glucose monitors — prior authorization required for Type 2 Diabetes (A9278, related codes).
Cosmetic/reconstructive procedures — many cosmetic codes require prior authorization; reconstructive procedures that restore physiologic function have specific CPTs requiring PA (see reconstructive list).
DME/Orthotics/Prosthetics — prior authorization required only for listed HCPCS when retail purchase or cumulative rental cost exceeds $500 (examples: A9279, A9280, A9900, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0460–E0471, L-codes listed).
Enteral and in-home nutritional therapy (B4034–B4036, B4100–B4104, B4149, B4150, B4152–B4153, B4150 series, A9274).
Femoroacetabular impingement (FAI) procedures (e.g., 29916).
FESS / Sinus procedures (e.g., 31240, 31253–31259, 31267, 31276, 31287–31288).
Gender dysphoria treatment (e.g., 55970, 55980; ICD codes F64.x).
Genetic and molecular testing — prior authorization required for many codes (U-codes and others; notification required for BRCA prior to sequencing).
Home health, hospice, private duty nursing, pediatric day services — prior authorization required for applicable settings/codes.
Joint replacement — selected joint/related procedures require prior authorization in acute care, rehabilitation, critical access and LTAC settings (examples: 23470–23474, 24360, 29867–29868, J7330, S2112).
Non-emergent air ambulance (A0430, A0431, A0435, A0436) requires prior authorization.
Orthognathic surgery codes (e.g., 21121, 21123, 21125, 21127, 21141, 21299) require prior authorization.
Potentially unproven services (e.g., 33289, C2624) require prior authorization.
Prostate procedures (e.g., 37243, 52441–52442, 53850, 53852, 55866, 55873–55874) require prior authorization.
Proton beam therapy (77520, 77522, 77523, 77525) requires prior authorization.
Radiology — advanced outpatient imaging (certain CT/MRI/MRA/PET, nuclear medicine/nuclear cardiology) requires prior authorization; providers must notify prior to scheduling.
Rhinoplasty/septoplasty and sinuplasty (e.g., 30400–30430, 30435, 30450–30462, 31295–31298) require prior authorization.
Site-of-service (SOS) — outpatient hospital setting may require prior authorization for many procedures; check SOS outpatient hospital lists prior to scheduling.
Spinal and neurosurgery procedures — extensive list of spine CPTs require prior authorization (examples: 22100–22224, 22510–22633, 22800–22861, 63001–63272, 63300–63306, 63250, etc.).
Neurostimulators and implantable devices — implantation of devices that send electrical impulses and associated CPT/HCPCS (E0747–E0760, neurostimulator CPTs, L8680, L8682, L8685–L8688, 61863–61868, 61885–61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590) require prior authorization.
Transplants, CAR T-cell and gene therapy — prior authorization/notification required; contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the number on the member ID card. CAR T-cell and T-cell/Gene therapy codes include 0537T–0540T, Q2041–Q2056, and gene therapy unclassified codes (C9399, C9400, J3490, J3590) — these require authorization handling.
Bone marrow/product and select unclassified codes — code 38232 requires PA only for oncology diagnoses; unclassified codes (C9399, J3490, J3590) for products such as Amtagvi, Casgevy, Lantidra, Lenmeldy, Skysona, etc., require prior authorization.
Vein procedures — endovenous and related CPTs (36468, 36473, 36475, 36478, 37700, 37718, 37722, 37765–37780) require prior authorization.
Ventricular assist devices (VAD) — prior authorization required; call the notification number on back of member ID and fax the form provided to Optum VAD Case Management Team at 855-282-8929.
Wound vacuum therapy (E2402) requires prior authorization.

Prior Authorization

Reconstructive / Cosmetic procedure authorization

Reconstructive versus cosmetic procedures: many cosmetic procedure codes require prior authorization; reconstructive procedures that treat a medical condition or restore physiologic function have their own PA code list. Providers should check the reconstructive CPT list before submitting.

Cosmetic codes examples (prior authorization required when listed): 15820–15823, 15830, 15847, 15877–15879, 17106–17108.
Reconstructive codes (examples): 17999, 21137–21139, 21172, 21181–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740–21743, 28344.
Reconstructive procedures that improve/restore physiologic function are considered separately from cosmetic; obtain PA as indicated.

Prior Authorization

Injectable medications — sample codes and notes

Injectable medications (including many specialty, oncology, and biologic agents) require prior authorization. Submit requests via the Provider Portal or call the phone numbers provided. The policy lists numerous J- and Q-codes and examples below.

Representative injectable sample codes include: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (colony-stimulating factors); J9000–J9999 (chemotherapy injectables); J0640–J0642 (leucovorin/levoleucovorin); J1950 (Lupron Depot).
Additional injectable examples: J3262 (Actemra®), J0801 (Acthar®), J1740 (factor products), J1413 (Elevidys), J7213, J2782, J1290 (Kalbitor®/Kanuma® referenced), J2840, J7190, J7211, J0879, J2507, J1411, J7170, J7199, J7187, J7202, J0638, J3245, Q5103, J1439, J1459, J1555–J1568, J3385, J3399 (Zolgensma®).
Specific specialty and high-cost injectables listed in policy require prior authorization (see full injectables list in policy).
For Kanuma® and Kalbitor® the HCPCS code J1290 is referenced — prior authorization is required for J1290 (Kanuma®) per the policy list.

Prior Authorization

Facility contexts and site-of-service prior authorization notes

Facility and site-of-service contexts: many L-codes and other procedure codes require prior authorization when billed by or for certain facility types (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals) or when performed in an outpatient hospital site of service.

L-code examples requiring PA when billed by/for listed facility contexts: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0640, L0700, L0710, L8610, L8612, L8631, L8659.
Site-of-service (SOS) outpatient hospital: prior authorization required when requesting service in an outpatient hospital setting for many procedures (examples across systems: 36590, 36832, 69205, 10121, 11440, 11450, 11624, 11770, 13121, 15100, 15120, 15240, 19020, 19120–19125, hernia repairs 49505, 49650–49651, colonoscopy, cataract surgeries 66821/66982/66984, select urologic procedures 52276–52344, liver biopsy, etc.).
Prior authorization may not be required if the service is performed at a participating Ambulatory Surgery Center for certain procedures; verify SOS rules before scheduling.

J1442, J1449, J1453, J1627, Q5110, Q5125 (among others shown in the injectable medications lists).

SettingPrior authorization required when these agents are administered in an outpatient setting for a cancer diagnosis.

inv-73: Prior authorization submission portal

Portal namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Alternate submissionPhone and fax contacts are provided in the document for specific requests (see relevant sections); portal is primary method referenced throughout.

How to accessClick the UnitedHealthcare Provider Portal button at UHCprovider.com, then select Prior Authorization and Notification on the Provider Portal dashboard.

inv-74: Auditory implant codes

Examples of codesCochlear implant and other auditory implant HCPCS codes include L8614, L8619, L8690, L8691, L8692.

Service noteCochlear and other auditory implants require prior authorization as listed in the document.

Associated CPTsRelated CPT procedure codes (e.g., 69710, 69714, 69930) are also cited in the auditory implant entries.

inv-75: DME prior authorization threshold

Threshold amount$500 retail purchase or cumulative rental cost

Applies toDME prior authorization threshold applies when retail purchase or cumulative rental cost for the listed DME HCPCS codes exceeds $500.

Example codesExamples of affected DME codes include A9279, E0471 and numerous E‑ and K‑series codes listed in the DME section.

inv-76: Prior authorization requirement

Requirement summaryPrior authorization is required for services explicitly labeled 'Prior authorization required' in the document (examples: enteral services, FESS, femoroacetabular impingement procedures, selected reconstructive and other procedures).

Where listedSee the specific CPT/HCPCS code lists and entries within the document sections for the services that state 'Prior authorization required.'

Provider actionProviders should submit requests via the Provider Portal Prior Authorization and Notification tool or follow contact instructions shown in each section.

inv-77: notification/prior authorization

Notification vs prior authorizationNotification/prior authorization: ordering provider or laboratory must notify UnitedHealthcare prior to testing when specified (example: BRCA testing requires notification/prior authorization before DNA sequencing).

ApplicabilityApplies to genetic and molecular tests listed in the genetic/molecular testing section (numerous U‑codes shown).

Provider responsibilityCare providers requesting these tests must follow the notification/prior authorization process described in the genetics section.

inv-78: J1290

Code mappingHCPCS code J1290 is repeatedly referenced in association with product names Kalbitor® and Kanuma® in the document's injectable medication entries.

ImplicationJ1290 entries indicate these specific drugs are included in the list of injectable medications referenced for prior authorization guidance.

Where to findSee injectable medications lists and J‑code entries in the General Information/injectable medications sections for details.

inv-79: CPT/HCPCS codes

UsageCPT and HCPCS codes are used throughout the document to list procedures, devices and medications that may require prior authorization.

ExamplesExamples include J‑codes for injectables (J2840, J7190, J7211), L‑codes for orthotics/prosthetics (L0112, L0456), and multiple CPT procedure codes (e.g., 31240, 29916).

Reference sectionsSee the injectable medications, DME, orthotics/prosthetics and procedural sections for the full code lists.

inv-80: UnitedHealthcare Provider Portal submission method

Primary methodPrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) is the referenced submission method for most requests.

Alternate contactsPhone numbers and fax are provided in sections for specific services (general phone 800‑600‑9007; some sections list specialty numbers such as 866‑889‑8054 for radiology/cardiology and 888‑397‑8129 for portal support).

Emergency exceptionPrior authorization is not required for emergency or urgent care; out‑of‑network providers must still request prior authorization for non‑emergent services.

inv-81: Orthotics and prosthetics prior authorization rule

RulePrior authorization is required for orthotics and prosthetic codes listed only when the retail purchase or cumulative rental cost exceeds $500.

Affected codesMultiple HCPCS L‑codes listed across the orthotics/prosthetics section (examples: L0112, L0464, L0482, L0631, L0810).

Facility noteThese entries are shown in context with facility types such as acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long‑term acute care hospitals.

inv-82: Prior authorization threshold

Threshold conditionPrior authorization required only for orthotics/prosthetic codes when the retail purchase or cumulative rental cost is more than $500.

Document locationStated repeatedly in the Orthotics and Prosthetics section across the numerous L‑code entries.

Provider actionObtain prior authorization via Provider Portal for items exceeding the $500 threshold; follow facility‑specific code guidance in the list.

inv-83: Facility types

ExamplesFacility contexts cited include acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long‑term acute care hospitals.

RelevanceThese facility types are noted alongside many L‑code orthotics/prosthetics entries to indicate the billing/site context for prior authorization requirements.

Where notedSee Orthotics and Prosthetics listings where each L‑code is shown with the four facility types.

inv-84: Proton beam therapy

DefinitionProton beam therapy: Focused radiation therapy using beams of protons (description provided in the document).

Prior authorizationProton beam therapy entries state 'Prior authorization required' with associated CPT codes (e.g., 77520, 77522, 77523, 77525).

Provider actionCare providers must request prior authorization via the Provider Portal or contact numbers listed for radiology prior authorization.

inv-85: Pediatric day services (PDHC)

ServicePediatric day services (PDHC) (CPT/HCPCS code T1024).

AuthorizationPDHC entries are labeled 'Prior authorization required'.

Related servicesPDHC is listed with other services that require prior authorization such as private duty nursing and potentially unproven services.

inv-86: Neurostimulator / bone growth stimulator

DefinitionNeurostimulator/bone growth stimulator: implantation of a device that sends electrical impulses.

Prior authorizationImplantation codes (E0747, E0748, E0749, E0760 and multiple CPT codes) require prior authorization.

ExamplesAssociated CPT entries include 43648, 61863, 63650 and other neurostimulator procedure codes listed in the implantable devices section.

inv-87: Transplant/CAR T-cell authorization

RequirementTransplant and CAR T‑cell therapy services require prior authorization and/or notification; providers must contact the UnitedHealthcare Community and State Transplant Case Management Team.

ContactCall the Transplant Case Management Team at 888‑936‑7246 or use the notification number on the back of the member's ID card.

ExamplesListed therapies include Abecma®, Breyanzi®, Kymriah™, Tecartus™ and Yescarta™ and associated procedure/Q‑codes shown in the transplants section.

inv-88: Ventricular assist devices (VAD)

DefinitionVentricular assist devices (VAD): A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Prior authorization stepsCall the notification number on the back of the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855‑282‑8929.

Associated codesVAD‑related CPT/Q codes include 33927, 33928, 33929, 33975, 33976 and related Q‑codes listed in the VAD section.

inv-89: Vein procedures / Removal and ablation

ScopeVein procedures (removal and ablation) for treating venous disease and varicose veins of the extremities are listed and require prior authorization.

Example CPT codesExamples include 36468, 36473, 36475, 36478, 37700, 37718, 37722 and 37765 as noted in the vein procedures and removal/ablation sections.

Provider actionSubmit prior authorization requests via the Provider Portal per the instructions in the vein procedures entries.