CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Virginia Cardinal Care LTSS

Lists services, procedures and drug products that require prior authorization for participating UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) providers and explains submission channels; applies to in-network and out-of-network providers delivering LTSS services in Virginia.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Virginia Cardinal Care LTSS

Policy CodePolicy N/A

Change TypeMinor/administrative (no material coverage change)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at the listed provider phone number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online & phonesubmission methods

J/Q codes listeddrug code groups

multipleservice categories

$500orthotics threshold

UHCprovider.com

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 and Drugs Requiring Prior Authorization

inv-01: Covered with prior authorization

Certain services and drugs are covered only with prior authorization as listed below.

Prior authorization is required for outpatient colony-stimulating factor drugs and bone-modifying agent when administered for a cancer diagnosis.

Colony-stimulating factor and related biosimilar products listed (examples include J1449, J1442, Q5110, Q5122, J2506, J1447) require prior authorization; several listed codes also require prior authorization for non-oncology diagnoses.

Bone-modifying agent Denosumab (J0897) requires prior authorization (see J0897-specific notes elsewhere in this policy).

Selected surgical and procedural services (examples: bariatric surgery CPTs 43644/43645/43842; breast reconstruction non-mastectomy CPTs 19316–19396 and HCPCS L8600) require prior authorization prior to performance.

inv-02: Coverage criteria examples

Covered when meeting the site- and indication-specific prior authorization rules below:

Inpatient video EEG (cerebral seizure monitoring) requires prior authorization for inpatient settings (CPT range 95700–95726).

Outpatient hospital or ambulatory surgical center video EEG (same CPT range) does not require prior authorization.

Injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) require prior authorization for a cancer diagnosis.

inv-03: Device and submission rules

Device and implant prior authorization examples and submission instructions:

Cochlear implants and other auditory implants require prior authorization (example CPTs 69710, 69714, 69930; HCPCS L8614).

Continuous glucose monitor and related device HCPCS codes (examples A9276–A9278, A9277, E0787, E2102–E2103) require prior authorization when indicated (continuous glucose monitor prior authorization is required with a type 2 diabetes diagnosis).

Submit prior authorization requests for devices and implants using the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone (provider contact shown in submission instructions).

inv-04: Partial coverage criteria and process notes

Exceptions, DME thresholds, and process notes:

Effective May 1, 2023, CPT codes 14020, 14021 and 14061 do not require prior authorization when billed with specified diagnosis codes per the exception noted in this policy.

Certain DME and related items require prior authorization when cost thresholds are exceeded (authorization required for DME with cost greater than $500 where noted).

Providers must submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the provider phone number listed in submission instructions for assistance.

inv-05: Coverage criteria pointers (partial)

Partial list of services and codes that require prior authorization (high-level pointers):

ONE of

Enteral services (in‑home nutritional therapy via enteral or gastrostomy tube) require prior authorization (examples B9002, B9004, B9006, B9998).
Gastrostomy tube procedures are listed as investigational/experimental in this policy and require prior authorization for review (example E0791).
Femoroacetabular impingement (FAI) arthroscopic procedure codes (29914–29916) require prior authorization.
Functional endoscopic sinus surgery (FESS) CPT codes listed require prior authorization (examples include 31240, 31253–31257, 31276, 31287–31288).
Genetic and molecular testing CPT codes (examples 81162, 81163, 81164, 81228, 81400–81408, 81410–81417, 81479, 81595) require prior authorization.

inv-06: Injectable medications prior authorization requirements (partial)

Injectable medications — prior authorization requirements and submission instructions (partial):

Numerous injectable medications listed in this policy require prior authorization; examples include Actemra (J3262), Acthar (J0801), Brineura (J0567), and many others enumerated in the injectable medications section.

Providers should submit injectable medication prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 for assistance, per submission instructions in this policy.

For new-to-market medications and products on the Review at Launch list, pre-determination is highly recommended; obtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800-310-6826.

inv-07: Prior authorization and notification requirements

Prior authorization and prior-notification requirements for specified codes and products:

For unclassified/temporary codes C9399, J3490 and J3590, prior authorization is required only when billing for specific listed products (examples: Casgevy, Lantidra, Lupaneta Pack, Lyfgenia, Nulibry, Revcovi, Rivfloza, Leqembi, Veopoz).

White blood cell colony-stimulating factor codes (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non-oncology diagnoses; oncology requests are handled via the Cancer supportive care section, and non-oncology submissions should be made online at UHCProvider.com using the Prior Authorization and Notification tool or via the Contact Us page.

Obtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800-310-6826.

inv-08: Prior authorization criteria (partial)

Selected prior authorization criteria (partial):

HCPCS code J0897 requires prior authorization effective Jan 1, 2023 (policy text notes prior authorization required for J0897 for non-oncology diagnoses).

Use the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888-397-8129 to request prior authorization as described in this policy.

inv-09: Prior authorization requirement

Specific prior authorization requirement called out in this section:

Prior authorization is required for HCPCS J0897 when used for non-oncology diagnoses (effective Jan 1, 2023); submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the provider phone line.

inv-10: Prior authorization criteria excerpt

Prior authorization requirements and special conditions (excerpt):

Submit prior authorization requests through UHCProvider.com or by calling 888-397-8129 as provided in the policy's submission instructions.

HCPCS code J0897 requires prior authorization effective Jan. 1, 2023 (see J0897 notes).

Non-emergent air ambulance transport requires prior authorization (examples mapped to A0430, A0431, A0435, A0436).

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500.

inv-11: Prior authorization-required services (partial list)

Services explicitly noted as requiring prior authorization or notification (partial list):

Private duty nursing services require prior authorization (examples: T1000, T1002, T1003, T1030, S9125).

Prostate procedures listed in the policy require prior authorization (examples include 37243, 52441, 52442, 53850, 53852, 55873, 55874).

Radiation therapy modalities (Image‑guided radiation therapy, Proton beam, IMRT, SRS/SBRT) require prior authorization for the CPT/HCPCS codes listed (examples include 77014, 77387, 77520, 77385, 77371).

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) requires notification or prior authorization prior to scheduling; submit requests via the UnitedHealthcare Provider Portal or call the radiology contact number.

Transplant and CAR T‑cell therapy services require prior authorization and case management contact (call UnitedHealthcare Community Plan Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card).

inv-12: Prior authorization and code-based coverage notes

Code- and service-based prior authorization and notification requirements (selected items):

Transplant and CAR T‑cell therapy services require prior authorization via Transplant Case Management; contact the Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's ID card.

Ventricular assist devices (VAD) require prior authorization/notification; call the notification number on the member's health plan ID card and fax the VAD form to the Optum VAD Case Management team at 855-282-8929.

Removal and ablation of saphenous veins for venous disease/varicose veins requires prior authorization (example CPTs include 36473, 36475, 37700, 37718, 37722, 37765, 37766).

Wound VAC therapy requires prior authorization (example HCPCS code E2402).

Related informational note

CPT, HCPCS and ICD-10 Codes Referenced

Selected procedural codes requiring prior authorizationCPT | HCPCSCovered

43644	Bariatric surgery
43645	Bariatric surgery
43842	Bariatric surgery
19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
L8600	Breast prosthesis (HCPCS)

Injectable supportive care drugsHCPCSCovered

J1449	Filgrastim (Neupogen)
J1442	Filgrastim-aafi (Nivestym) — requires prior auth for non-oncology Dx
Q5110	Filgrastim-ayow (Releuko)
Q5122	Pegfilgrastim-apgf (Nyvepria)
J0897	Denosumab (Xgeva) — bone-modifying agent

Diabetes-related diagnosis codesICD-10Covered

E09.52	Diabetes mellitus due to an underlying condition with foot ulcer (example listed)
E10.52	Type 1 diabetes with foot ulcer (listed)
E11.52	Type 2 diabetes with foot ulcer (listed)

Osteomyelitis diagnosis codesICD-10Covered

M86.*

Multiple osteomyelitis ICD-10 codes (M86.051 through M86.9 and subcodes) listed as requiring prior authorization

Selected CPT/HCPCS device and monitoring codesmixedCovered

95700-95726	Cerebral seizure monitoring inpatient video EEG CPT codes
A4226, A4239, A9276-9278, E0787, E2102-E2103	Continuous glucose monitor and related device HCPCS codes

Sample ICD-10 and HCPCS codes referencedICD-10 | HCPCS

C43.0	Melanoma of lip (listed among ICD-10 codes referenced)
C44.01	Malignant neoplasm of skin of unspecified eyelid, including canthus (example ICD-10 listed)
A9279	DME-related HCPCS code (example listed)

Durable medical equipment (DME) codesHCPCSCovered

E0265	DME: Example equipment code referenced
E0445	DME: Enteral supply code referenced

DME/orthotics/prosthetics HCPCS codes (partial)HCPCS

E0265	Durable medical equipment (DME) code listed
E0270	DME code listed
E0328	DME code listed
E0445	DME code with additional information (cost > $500 noted)
K0005	Seating/wheelchair related HCPCS code listed

Genetic/molecular testing CPT codes (partial)CPT

81162	Genetic/molecular testing CPT code
81479	Genetic/molecular testing CPT code

Injectable medication J-codes (partial)HCPCS

J3262	Actemra (example injectable) HCPCS/J-code
J0801	Acthar HCPCS/J-code

Injectable medication HCPCS/J-codes (partial list)HCPCSCovered

J3262	Actemra
J0801	Acthar
J9220	Example — many additional J-codes listed across sections

Unclassified/temporary codes with product exceptionsHCPCSCovered

C9399	Unclassified temporary code (PA only required for specified products)
J3490	Unclassified drug code (PA only required for specified products)
J3590	Unclassified drug code (PA only required for specified products)

HCPCS/CPT codes requiring prior authorizationHCPCSCovered

C9399	Unclassified/temporary code — prior authorization required for listed specialty drugs
J3490	Unclassified/temporary code — prior authorization required for listed specialty drugs
J3590	Unclassified/temporary code — prior authorization required for listed specialty drugs
J1442	White blood cell colony-stimulating factor — prior authorization required
J1447	White blood cell colony-stimulating factor — prior authorization required
J1448	White blood cell colony-stimulating factor — prior authorization required
J2506	White blood cell colony-stimulating factor — prior authorization required
Q5101	White blood cell colony-stimulating factor — prior authorization required
Q5108	White blood cell colony-stimulating factor — prior authorization required
Q5110	White blood cell colony-stimulating factor — prior authorization required

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HCPCS codes requiring prior authorization (partial)HCPCSCovered

J0897

Referenced HCPCS code; prior authorization required effective Jan 1, 2023

HCPCS codes with PA notesHCPCSCovered

J0897

Monoclonal antibody injection — prior authorization required for non-oncology diagnoses effective Jan. 1, 2023

Selected code mappings from listHCPCS | CPT | mixed

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport
A0435	Non-emergent air ambulance transport
A0436	Non-emergent air ambulance transport
21121	Orthognathic surgery (example mapping)
L0112	Orthotics/prosthetics example

Orthotics/ProstheticsHCPCSCovered

L5321	Orthotics/prosthetics code listed
L5341	Orthotics/prosthetics code listed
L5400	Orthotics/prosthetics code listed
L8499	Orthotics/prosthetics miscellaneous code listed

Private duty nursingCPT | HCPCSCovered

T1000	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing
T1030	Private duty nursing
S9125	Private duty nursing

Radiation therapy groupsCPT | HCPCSCovered

77014	Radiation therapy imaging/IGRT
77387	Radiation therapy
G6001	Radiation therapy related code
77520	Proton beam therapy
77385	IMRT planning
77371	SRS/SBRT

NeurostimulatorsCPT | HCPCSCovered

61863	Neurostimulator implantation / trial codes referenced
63650	Neurostimulator implantation code mapping
L8680	Neurostimulator HCPCS codes

Potentially unproven servicesCPT | HCPCSExperimental

33289	Potentially unproven services example code
C2624	Potentially unproven services HCPCS

Neurostimulator-related codesCPT

61863-61868	Neurostimulator/implantation related CPT cross-references
63650-63655	Neurostimulator implantation codes referenced

CAR T-cell therapy codesHCPCS

Q2041-Q2056

CAR T-cell therapy HCPCS Q-codes referenced

Wound care codesHCPCSCovered

E2402

Wound VAC HCPCS code

DME cost threshold

ThresholdAuthorization required for durable medical equipment (DME) when item cost is more than $500.

Examples (from list)E0445 is listed with ‘cost of more than $500’ noted; other DME codes referenced include E0265, E0270, E0328.

How to Submit Requests and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (UHCprovider.com) or by phone at 844-284-0146. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

Prior Authorization

Services that require prior authorization (selected examples)

Examples of clinical services that require prior authorization include bariatric surgery (e.g., CPT 43644, 43645, 43842), behavioral health services (refer to the number on the member’s ID card for specific codes), bone growth stimulators (CPT 20975, 20979), brain injury case management, and breast reconstruction (non‑mastectomy) procedures (multiple CPTs listed such as 19316, 19318, 19368).

Prior Authorization

Drug prior authorization — cancer supportive care

Key Terms and Thresholds

Prior authorization — Term

DefinitionPrior authorization — A determination required before certain services, devices or drugs are provided; requests are submitted via the UnitedHealthcare Provider Portal or by phone per instructions in this list.

Not required forEmergency or urgent care do not require prior authorization as stated in the document.

Out-of-network providersOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Provider Portal

Portal nameUnitedHealthcare Provider Portal (Prior Authorization and Notification tool) — sign in at UHCprovider.com.

Access detailsLog in with One Healthcare ID; use the Prior Authorization and Notification tab on the dashboard to submit requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Virginia Cardinal Care LTSS

Policy CodePolicy N/A

Change TypeMinor/administrative (no material coverage change)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone at the listed provider phone number.

SourceLink

On This Page

Home health care services require prior authorization only in outpatient settings including the member's home (examples G0299, G0300, G0493–G0496, S9123–S9124).

Hysterectomy procedures (multiple listed CPTs such as 58150, 58152, 58180, 58260, 58262, 58263, 58542–58573) require prior authorization.

Neurostimulator implantation and related procedures are cross-referenced to multiple CPT/HCPCS codes and are included in the policy's prior authorization requirements for implantable devices.

How appliedPrior authorization must be obtained for DME items above this cost threshold before service/provision.

Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization required for orthotics and prosthetics with a retail purchase or cumulative rental cost greater than $500.

Examples (codes shown)Orthotics/prosthetics example HCPCS codes listed near this rule include L0112, L0170, L0456, L0462 and others.

ApplicationThe $500 threshold applies to either a single retail purchase or the total cumulative rental cost for the item(s).

Cancer supportive care outpatient drugs—specifically colony‑stimulating factor drugs and bone‑modifying agents—require prior authorization (examples include J1449, J1442, Q5110, Q5122, J2506; denosumab J0897 is listed as a bone‑modifying agent).

Prior Authorization

Cardiology prior authorization requirements

Cardiology/cardiovascular services require prior authorization for many outpatient diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance; lower‑extremity angiogram also requires prior authorization.

Prior Authorization

How to submit prior authorization requests

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal at UHCprovider.com or call the prior authorization phone line listed for assistance (examples in document show 888‑397‑8129 for many listed services).

Prior Authorization

Cerebral seizure monitoring - inpatient video EEG

Inpatient video electroencephalogram (video EEG) for cerebral seizure monitoring requires prior authorization when performed inpatient; the same services do not require prior authorization when performed outpatient or in an ambulatory surgical center (CPTs 95700–95726 listed).

Prior Authorization

Chemotherapy prior authorization

Injectable chemotherapy drugs administered in an outpatient setting (including IV, intravesical and intrathecal) require prior authorization when used for a cancer diagnosis.

Prior Authorization

Device and implant prior authorization examples

Certain devices and implants require prior authorization—examples include cochlear implants (CPTs 69710, 69714, 69930; HCPCS L8614–L8692) and continuous glucose monitors (HCPCS A4226, A4239, A9276–A9278); specific HCPCS device codes listed in the document require prior authorization.

Prior Authorization

Cosmetic and reconstructive procedures

Numerous cosmetic and reconstructive procedure CPT codes are listed and require prior authorization; examples include 11960, 11971, 14020, 14021, 14061, 14301, 15820 and many others (submission via provider portal or phone).

Prior Authorization

Submission channels for prior authorization

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed prior authorization phone number (document examples include 888‑397‑8129) for the services and codes shown.

Note

Prior authorization exceptions (partial)

Effective May 1, 2023, codes 14020, 14021 and 14061 do not require prior authorization when billed with certain diagnosis codes as specified in the document.

Prior Authorization

Enteral services prior authorization

Enteral services—home in‑home nutritional therapy delivered enterally or via gastrostomy tube (examples B9002, B9004, B9006, B9998)—require prior authorization.

Prior Authorization

Gastrostomy tube (investigational/experimental)

Gastrostomy tube services are listed in the investigational/experimental section (example HCPCS E0791); investigational/experimental services require prior authorization for review.

Prior Authorization

FAI procedures prior authorization

Femoroacetabular impingement (FAI) arthroscopic procedure codes (29914–29916) require prior authorization.

Prior Authorization

FESS prior authorization

Functional endoscopic sinus surgery (FESS) CPT codes (e.g., 31240, 31253–31259, 31267, 31276, 31287–31288) require prior authorization.

Prior Authorization

Gender dysphoria treatment prior authorization

Gender dysphoria treatment surgeries require prior authorization for numerous listed surgical CPT codes and associated diagnosis codes (F64.x referenced); many specific CPTs are enumerated in the policy.

Prior Authorization

Genetic/molecular testing prior authorization

Genetic and molecular testing CPT codes (many listed, e.g., 81162, 81479 and numerous others) require prior authorization per the document.

Prior Authorization

Home health care prior authorization

Home health care codes used in outpatient settings including the member’s home (examples G0299, G0300, G0493–G0496, S9123–S9124) require prior authorization.

Prior Authorization

Hysterectomy prior authorization

Hysterectomy procedures require prior authorization for the listed CPT codes (examples include 58150, 58152, 58180, 58260, 58262–58263 and others shown).

Prior Authorization

Injectable medications prior authorization and submission instructions

Injectable medications listed in the policy require prior authorization; providers are instructed to submit requests via the UnitedHealthcare Provider Portal or call 888‑397‑8129 for assistance.

Prior Authorization

Submission channels

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 (document repeatedly references this phone number for PA assistance).

Prior Authorization

Optum Rx prior notification and Review at Launch

Obtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800‑310‑6826; pre‑determination is recommended for drugs on the Review at Launch Medication List.

Prior Authorization

Unclassified/temporary codes rule

For unclassified/temporary codes C9399, J3490 and J3590, prior authorization is required only when billing for specified products (examples: Casgevy, Lantidra, Lupaneta Pack, Lyfgenia, Nulibry, Revcovi, Rivfloza, Leqembi, Veopoz).

Prior Authorization

Colony-stimulating factor prior authorization requirement

White blood cell colony‑stimulating factor HCPCS/Q codes (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non‑oncology diagnoses; oncology Dx handled in the Cancer supportive care section.

Prior Authorization

Prior auth required for unclassified/temporary codes

Prior authorization is required when billing unclassified/temporary codes C9399, J3490 and J3590 for the listed specialty drugs (see product list in policy).

Prior Authorization

Prior auth for colony-stimulating factor codes

White blood cell colony‑stimulating factor codes listed (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for oncology and non‑oncology diagnoses; non‑oncology requests should be submitted online via UHCProvider.com Prior Authorization and Notification tool or via the Contact Us page.

Prior Authorization

Optum Rx prior notification for Cimzia and Synagis

Obtain prior notification for Cimzia and Synagis through Optum Rx prior notification services at 800‑310‑6826 (document reiterates Optum Rx contact for these products).

Documentation Required

Submission methods for prior authorization

Non‑oncology prior authorization requests should be submitted online at UHCProvider.com using the Prior Authorization and Notification tool; providers can also use the Contact Us page or call the UnitedHealthcare Provider Portal phone number (example 888‑397‑8129) for assistance.

Prior Authorization

How to obtain prior authorization

Obtain prior authorization via the UHCprovider.com portal or by calling 888‑397‑8129; effective Jan 1, 2023 prior authorization is required for J0897 for non‑specified indication(s) as noted in the document.

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone number (document examples use 888‑397‑8129); prior authorization is required for J0897 effective Jan 1, 2023 for non‑oncology diagnoses as specified.

Prior Authorization

Non-emergent air ambulance transport prior authorization

Prior authorization is required for non‑emergent air ambulance transport (mapped HCPCS A0430, A0431, A0435, A0436).

Prior Authorization

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds $500.

Prior Authorization

How to submit prior authorization requests

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054 for services where that contact is specified (example: standard radiation therapy prior authorization contact in that section).

Prior Authorization

Radiology prior notification and authorization

Health care professionals ordering advanced outpatient imaging (CT/MRI/MRA/PET, nuclear medicine) must provide notification prior to scheduling; submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054.

Prior Authorization

Transplant/CAR T-cell prior authorization contact

For transplant and CAR T‑cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) call the UnitedHealthcare Community Plan Transplant Case Management team at 888‑936‑7246 or the notification number on the member’s ID card.

Prior Authorization

Private duty nursing prior authorization

Private duty nursing requires prior authorization (codes T1000, T1002, T1003, T1030, S9125 are listed in the policy).

Prior Authorization

Transplant and CAR T-cell therapy prior authorization contact

For transplant and CAR T‑cell therapy services (including Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta) contact UnitedHealthcare Community Plan Transplant Case Management at 888‑936‑7246 or use the notification number on the back of the member’s ID card.

Prior Authorization

VAD prior authorization/contact procedure

For ventricular assist devices (VAD) call the notification number on the back of the member’s health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855‑282‑8929.

Prior Authorization

Venous ablation prior authorization requirement

Removal and ablation of the main trunks and named branches of the saphenous veins for venous disease/varicose veins requires prior authorization (CPT examples include 36473, 36475, 37700, 37718, 37722, 37765, 37766).

Prior Authorization

Wound VAC prior authorization

Wound VAC services require prior authorization; the policy lists HCPCS code E2402 as an example.

Alternate assistanceProvider portal support and phone assistance details are provided in the document (see phone contacts).

UHCprovider.com

NameUHCprovider.com — the UnitedHealthcare Provider Portal web site for submitting prior authorization and notification requests.

How to useGo to UHCprovider.com, click Sign In and access the Prior Authorization and Notification tab on your dashboard.

Alternate contactIf you do not have a One Healthcare ID, visit UHCprovider.com/access for account setup instructions.

DME (Durable medical equipment)

TermDurable medical equipment (DME) — medical equipment items referenced by HCPCS codes (examples: E0265, E0328, E0445) for which prior authorization rules apply.

Cost ruleSome DME items require prior authorization when cost exceeds $500 (see DME cost threshold).

Examples listedDocument lists multiple DME HCPCS codes and notes on rental vs. purchase application.

Prior authorization required — Clarification

StatementPrior authorization required — The document explicitly states that specified services, devices and medications listed in the file require prior authorization before provision.

Scope examplesExamples include enteral services, many injectable medications, orthotics/prosthetics above the $500 threshold, and certain procedures (e.g., FESS, FAI, hysterectomy).

SubmissionRequests must be submitted online via UHCprovider.com Prior Authorization and Notification tool or by phone where indicated.

Investigational/experimental

DefinitionInvestigational/experimental — Services or devices listed as experimental/investigational in the document require prior authorization for review (e.g., certain gastrostomy tube entries are labeled investigational/experimental).

ExamplesGastrostomy tube and other items are cited in the experimental/investigational section and require prior authorization for review.

ImplicationWhen a service/device is designated investigational/experimental, prior authorization must be obtained to permit case-by-case evaluation.

Review at Launch

ProgramReview at Launch — See the Review at Launch for New to Market Medications policy and the Review at Launch Medication List for newly FDA-approved drugs; pre-determination is highly recommended for drugs on this list.

NotificationPre-determination and prior notification are recommended for drugs included on the Review at Launch list.

ContactFor some products (e.g., Cimzia, Synagis) obtain prior notification through Optum Rx at 800-310-6826 as noted in the document.

C9399, J3490, J3590 (Unclassified/temporary codes)

CodesC9399, J3490, J3590 — Unclassified/temporary HCPCS/J-codes; prior authorization is required only when used for specified products named in the document (e.g., Casgevy, Lantidra, Leqembi, Veopoz).

ApplicationWhen billing these unclassified/temporary codes for listed specialty products, obtain prior authorization per the guidance in the file.

ReferenceSee the list of specified products in the document where these unclassified/temporary codes trigger PA requirements.

Colony-stimulating factor (CSF) codes requiring prior authorization

Codes listedJ1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 — White blood cell colony-stimulating factor codes.

RequirementThese colony-stimulating factor codes require prior authorization for both oncology and non-oncology diagnoses; oncology Dx handled in Cancer supportive care section; non-oncology submissions use UHCProvider.com Prior Authorization and Notification tool.

Submission noteFor non-oncology diagnoses, submit requests online at UHCProvider.com or use the Contact Us page per the document instructions.

Prior authorization request channel

Primary channelUHCprovider.com — submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Phone alternativeProvider assistance and some PA submissions can be conducted by phone; document lists phone contact numbers (for example, 888-397-8129 is repeatedly cited for assistance).

Contact detailsPortal sign-in uses One Healthcare ID; if you don’t have one, visit UHCprovider.com/access for setup instructions.

UnitedHealthcare Provider Portal

PortalUnitedHealthcare Provider Portal — the web portal (UHCprovider.com) designated for submitting prior authorization and notification requests.

How to sign inGo to UHCprovider.com and click Sign In; use your One Healthcare ID and password, then select the Prior Authorization and Notification tab.

AvailabilityPortal submission is the preferred method; the document repeatedly directs users to submit requests online via UHCprovider.com.

PA phone line

Phone supportPA phone line — Provider assistance phone numbers are provided for prior authorization; the document repeatedly references 888-397-8129 (and 844-284-0146 for other contexts).

When to callUse the phone line for assistance with submissions, or when instructed by specific service sections that list phone alternatives to portal submission.

Case-specific contactsCertain services (e.g., transplant/CAR T, VAD) have specialized contact numbers cited elsewhere in the document (see case management phone numbers).

UHCprovider.com portal for submitting prior authorization requests

Primary portal instructionUse the UnitedHealthcare Provider Portal (UHCprovider.com) — specifically the Prior Authorization and Notification tool — to submit prior authorization requests.

Alternate methodsIf portal submission is not possible, the document provides phone contact options and a Contact Us page for 24/7 assistance.

Sign-in requirementA One Healthcare ID is required to sign in; account setup instructions available at UHCprovider.com/access.

Orthotics/prosthetics PA threshold (retail or cumulative rental > $500)

Rule summaryPrior authorization is required for orthotics and prosthetics only when the retail purchase price or the cumulative rental cost exceeds $500.

Related DME ruleThe DME section similarly specifies prior authorization for DME items above $500 (see DME cost threshold).

Examples/codesOrthotics/prosthetics example HCPCS codes referenced near the threshold include L0112, L0170, L0456, L0462 and many L-series codes.

Proton beam (definition)

DefinitionProton beam — Focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Example codesListed CPT/HCPCS codes for proton beam therapy include 77520, 77522, 77523 and 77525.

ContextProton beam is grouped with radiation therapy services that may require prior authorization per the radiation therapy section.

IMRT (definition)

DefinitionIMRT — Intensity-modulated radiation therapy (IMRT) and associated CPT/HCPCS codes are listed in the document.

Example codesIMRT-related codes cited include 77385 and 77386 (plus related special/associated services like 77331, 77370).

Usage noteIMRT is part of the radiation therapy groups for which prior authorization is noted in the document.

SRS/SBRT (definition)

DefinitionSRS/SBRT — Stereotactic radiosurgery and stereotactic body radiation therapy; CPT/HCPCS codes for these services are listed.

Example codesCodes shown include 77371, 77372, 77373 and G0339, G0340.

ContextThese high-precision radiation therapies are included in the radiation therapy groups requiring prior authorization in many cases.

Ventricular assist devices (VAD)

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

Prior authorization/contactPrior authorization is required; the document instructs providers to call the notification number on the member’s ID card and to fax required forms to Optum VAD Case Management at 855-282-8929.

Example codeDocument references CPT/HCPCS mapping including 33927 and other VAD-related codes in the VAD section.

Removal and ablation of saphenous veins (definition)

DefinitionRemoval and ablation of saphenous veins — Procedure to treat venous disease and varicose veins of the extremities involving removal and ablation of main trunks and named branches of the saphenous veins.

Prior authorizationThis procedure group requires prior authorization as stated in the radiology/procedures section.

Example codesThe document cross-references CPT codes used in these procedures (e.g., 36473, 36475, 37700, 37718, 37722, 37765, 37766).