CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Mississippi Children's Health Insurance Program

Lists services and CPT/HCPCS codes that require prior authorization for UnitedHealthcare Community Plan providers serving Mississippi CHIP members, and explains how to submit requests. Applies to in-network and out-of-network providers serving Mississippi CHIP members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Mississippi Children's Health Insurance Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Oct. 1, 2024effective date

Online, Phone, Faxauthorized submission methods

877-842-3210phone for prior auth

888-310-6858fax for prior auth

Optum Behavioral Health

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.

behavioral health network

Prior Authorization Coverage Criteria

Prior authorization codes (partial)

Partial list of CPT/HCPCS/J/Q codes and injectable medications that require prior authorization for outpatient services or specialized programs. This list is not exhaustive; contact the plan for any codes not shown. For many categories (e.g., behavioral health, transplant, radiation, chemotherapy, site-of-service), prior authorization instructions direct providers to use the portal or call the notification numbers shown.

Prior authorization is required for select injectable medications (outpatient). Examples include: Actemra (J3262), Acthar (J0801), Adakveo (J0791), Aduhelm (J0172), Adzynma (J7171), Aldurazyme (J1931), Amvuttra™ (J0225), Amondys 45 (J1426), Aralast NP® (J0256), Avsola™ (Q5121). [See chunk 96, 43]

Cancer supportive care drugs (colony-stimulating factors and bone-modifying agents) administered outpatient require prior authorization. Examples of HCPCS/J/Q codes: J1449, J1442, J2506, Q5110, Q5125, Q5122, Q5111. Filgrastim and pegfilgrastim biosimilars and branded products listed require PA. [See chunk 43]

Chemotherapy injectable drugs administered outpatient require prior authorization. This includes drugs billed J9000-J9999 range, leucovorin (J0640), levoleucovorin (J0641,J0642), Lupron Depot (J1950), leuprolide (J1952), chemotherapy Q-codes, and miscellaneous unassigned HCPCS codes. Submission via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling the number provided. [See chunk 46]

Durable Medical Equipment (DME) prior authorization is required only for codes listed with a retail purchase or cumulative rental cost > $500. Examples of HCPCS codes requiring PA include: A6549, B4152, E0266, E0328, E0460, A9279, B4161, E0270, E0329, E0465, E0483, E0636, E0670, E0700, E0764, E0953, E0957, E1002, E1006, E1010, E1036, E1229, E1234, E1238, E2100, E2209, E2227, E2298, A9280, E0194, E0277, E0445, E0466, E0486, E0637, E0675, E0710, E0766, E0954, E0960, E1003, E1007, E1028, E1130, E1231, E1235, E1239, E2201, E2211, A9900, E0265, E0300, E0457, E0470, V5287, V5288, V5290. [See chunk 68, 87]

Enteral and parenteral nutrition and supplies require prior authorization. Examples of HCPCS codes: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4153, B4155, B4158, B4159, B4160, B9002, B9998, B9999. [See chunk 87, 88]

Experimental and investigational services require prior authorization. Examples of CPT/HCPCS include: 36514, 64722, 65765, 65767, 66180, A4226, A4638. [See chunk 87]

Cochlear and other inner ear device codes require prior authorization. Examples: 69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692. [See chunk 48, 131]

Cosmetic and reconstructive procedures may require prior authorization. Examples include CPT codes: 11960, 14020, 14021, 14041, 14061, 15820, 15821, 15822, 15823, 15830. (Some cosmetic codes marked with * have contextual PA exceptions.) [See chunk 48]

Breast reconstruction and related codes: examples requiring PA include 11971, 19316, 19318, 19328, 19330, 19350, 19357, 19364, 19367, 19368, 19369, 19370. [See chunks 2-4, 18]

Joint replacement and related orthopedic procedure codes require prior authorization. Examples include: 23470, 23472, 23473, 23474, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446, 27447, 27486, 27487, 29866, 29867, 29868, J7330, S2112. [See chunks 111-112]

Orthognathic surgery and related maxillofacial codes require PA. Examples: 21121, 21123, 21125, 21127, 21141. [See chunk 111]

Outpatient therapies (speech) require prior authorization. Example CPT: 92507. [See chunk 131]

Pain injections and management procedures require PA. Example CPTs include: 64490, 64493. [See chunk 131]

Prostate procedures require PA. Examples: 37243, 52441, 52442, 53850, 53852, 55873, 55874. [See chunk 131]

Private duty nursing codes require prior authorization. Examples: S9122, S9123, S9124, T1000, T1001, T1002, T1003. [See chunk 132]

Radiation therapy services require prior authorization. Example codes/identifiers include IGRT, 77014, 77387, G6001, G6002. Providers instructed to use the Prior Authorization and Notification tool or call the portal number. [See chunks 112, 139, 140]

Septoplasty, rhinoplasty and sinuplasty procedures require PA. Examples: 30400, 30410, 30420, 30430, 30435, 31295-31298. [See chunk 139]

Sleep studies and sleep apnea surgeries require PA. Examples: diagnostic/sleep study CPTs 95805, 95807, 95808, 95810, 95811; sleep apnea surgical codes include 21685, 41599, 42145. [See chunks 153-154]

Spinal surgery codes require prior authorization. Examples include: 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22212, 22214, 22220, 22224. [See chunk 154]

Neurostimulator and implantable device procedures require PA. Examples of CPT/HCPCS and device codes: E0747, E0748, E0749, E0760, 61863-61868, 61885-61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570. [See chunks 159-160]

Transplant and CAR T-cell therapies require prior authorization and coordination with the UnitedHealthcare Community and State Transplant Case Management team; call 888-936-7246 for notification and authorization. [See chunk 162]

Vein procedures (saphenous removal/ablation) require PA. Examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766. [See chunk 168]

Ventricular assist devices (VAD) and related services require prior authorization; contact the notification number on the member ID card or VAD case management. [See chunks 169-171]

Wound vacuum (wound vac) supplies and codes require prior authorization. Example HCPCS: E2402; VAD case management contact 855-282-8929 for related coordination. [See chunk 171]

Codes and Coding Guidance

Bariatric surgery codesCPTCovered

43644	Bariatric surgery - requires prior authorization
43775	Bariatric surgery - requires prior authorization
43645	Bariatric surgery - requires prior authorization
43842	Bariatric surgery - requires prior authorization
43659	Bariatric surgery - requires prior authorization
43845	Bariatric surgery - requires prior authorization
43770	Bariatric surgery - requires prior authorization
43846	Bariatric surgery - requires prior authorization

Bariatric surgery codes (duplicate entry in source)CPTCovered

43770	Bariatric surgery - requires prior authorization (duplicate listing)
43846	Bariatric surgery - requires prior authorization (duplicate listing)

Bone growth stimulator codesCPTCovered

20975	Bone growth stimulator
20979	Bone growth stimulator

Breast reconstruction and mastectomy-related codesmixedCovered

11971	Breast reconstruction (non-mastectomy)
19316	Breast reconstruction (non-mastectomy)
19318	Breast reconstruction (non-mastectomy)
19328	Reconstruction of the breast except when following mastectomy
19330	Reconstruction of the breast except when following mastectomy
19350	Reconstruction of the breast except when following mastectomy
19357	Reconstruction of the breast except when following mastectomy
19364	Reconstruction of the breast except when following mastectomy
19367	Mastectomy-related reconstruction
19368	Mastectomy-related reconstruction

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Referenced CPT codesCPT

19367	CPT code listed in section (repeated)
19368	CPT code listed in section (repeated)
19369	CPT code listed in section (repeated)
19370	CPT code listed in section (repeated)

Cancer supportive care - covered with PAHCPCS

J1449	Eflapegrastim-xnst (Rolvedon®) or related filgrastim products
J2506	Pegfilgrastim (Neulasta®)
J0897	Denosumab (Xgeva®)
J0885	Erythropoiesis-stimulating agents

Chemotherapy injectables - covered with PAHCPCS

J9000-J9999	Chemotherapy injectable drugs requiring prior authorization
J0640	Leucovorin
J0641	Levoleucovorin

Cochlear devices - covered with PAmixed

69710	Cochlear implant procedures
L8614	Cochlear device HCPCS

Skin lesion / lesion excision coding exceptionsmixed

.67917 .67924 .Q2026

List of procedure codes with annotations; prior authorization not required when billed with specific ICD-10 codes (e.g., C43.x, C44.x series)

ICD-10 diagnoses exempt from prior authorization when billed with specified CPT/HCPCSICD-10Covered

C44.*

Multiple skin cancer ICD-10 codes (various subcodes) listed where prior authorization is not required when billed with enumerated CPT/HCPCS codes.

DME/HCPCS code listsHCPCSCovered

D03/D04/D04.*

DME-related internal grouping codes referenced alongside many HCPCS E-codes that require authorization over threshold.

Example DME HCPCS entries (from listing)HCPCSCovered

A6549	DME HCPCS listed in the source
B4152	DME HCPCS listed in the source
E0266	DME HCPCS listed in the source

Selected HCPCS/CPT groups needing prior authorizationmixedCovered

B4034	Enteral/parenteral supplies
B4100	Enteral nutrition formula/equipment (examples)
B4150	Gastrostomy tube feeding supplies
36514	Experimental/investigational procedure example
31240	FESS CPT example
29914	FAI procedure CPT example
81162	BRCA gene testing example

Selected injectable medication codesHCPCSCovered

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J0172	Aduhelm
J7171	Adzynma
J1931	Aldurazyme
J0225	Amvuttra
J1426	Amondys 45
J0256	Aralast NP / Prolastin C / Zemaira (listed)
Q5121	Avsola

Genetic testing codes (BRCA and others)CPTCovered

81162	Genetic/molecular testing code
81400	Genetic/molecular testing code
81415	Genetic/molecular testing code
81420	Genetic/molecular testing code

Injectable/biologic HCPCS codes referencedHCPCSCovered

J3401	Vyjuvek™
J1429	Vyondys 53®
J9334	Xembify®
J1558	Xembify® / Xenpozyme™ (appears multiple entries)
J0218	Xenpozyme™

Orthotics/prosthetics L-codes (partial list)HCPCSCovered

L0112	Orthotic/prosthetic example (L-code)
L5960	Orthotic/prosthetic example
L6010	Orthotic/prosthetic example

Joint replacement and related CPT codes (examples from list)CPTCovered

27130	Total hip arthroplasty (example joint replacement CPT codes listed)
27447	Knee arthroplasty (example joint replacement CPT codes listed)
23470	Shoulder procedure (example CPT code included in joint replacement section)

Selected CPT/HCPCS codes with prior authorization requirementmixedCovered

92507	Speech therapy CPT code listed (prior authorization required)
64490	Pain injection/management CPT code (prior authorization required)
64493	Pain injection/management CPT code (prior authorization required)
37243	Prostate procedure CPT code (prior authorization required)
52441	Prostate procedure CPT code (prior authorization required)
52442	Prostate procedure CPT code (prior authorization required)
53850	Prostate procedure CPT code (prior authorization required)
S9122	Private duty nursing HCPCS code (prior authorization required)
S9123	Private duty nursing HCPCS code (prior authorization required)
S9124	Private duty nursing HCPCS code (prior authorization required)

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Radiation therapy CPT/HCPCS entriesmixedCovered

77520	Proton beam therapy CPT
77522	Proton beam therapy CPT
77523	Proton beam therapy CPT
77525	Proton beam therapy CPT
77331	Radiation therapy associated service
77370	Radiation therapy associated service
77399	Radiation therapy associated service
77401	Standard radiation therapy CPT
77402	Standard radiation therapy CPT
77407	Standard radiation therapy CPT

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Selected outpatient hospital procedure codesCPT

10121	Outpatient hospital - integumentary procedures
11440	Outpatient hospital - integumentary procedures
43235	Upper gastrointestinal endoscopy
52276	Urinary system procedure

Spinal surgery codesCPT

22100	Spinal surgery
22510	Spinal fusion procedures
22630	Spinal fusion

Neurostimulator and device codesmixed

L8680	Neurostimulator supply code
64553	Insertion/implantation neurostimulator
63650	Neurostimulator implantation

Neurostimulator and related CPT/HCPCS codes (partial list)CPTCovered

32850	Neurostimulator-related code listed
32851	Neurostimulator-related code listed
32852	Neurostimulator-related code listed
32853	Neurostimulator-related code listed
32854	Neurostimulator-related code listed
32855	Neurostimulator-related code listed
32856	Neurostimulator-related code listed
33930	Neurostimulator-related code listed
33933	Neurostimulator-related code listed

Vein proceduresCPTCovered

36473	Vein ablation/removal code
36475	Vein ablation/removal code
36478	Vein ablation/removal code
37700	Vein procedure code
37718	Vein procedure code
37722	Vein procedure code
37765	Vein procedure code
37766	Vein procedure code

VAD and wound vac codesmixedCovered

33927	Ventricular assist device code
33928	Ventricular assist device code
33929	Ventricular assist device code
33975	Ventricular assist device code
33976	Ventricular assist device code
33979	Ventricular assist device code
33981	Ventricular assist device code
33982	Ventricular assist device code
33983	Ventricular assist device code
Q0507	VAD-related HCPCS code

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DME prior authorization monetary threshold

DME prior authorization thresholdRetail purchase or cumulative rental cost over $500 requires prior authorization for DME items listed.

Prosthetics exclusionProsthetics are not considered DME for prior authorization; see Orthotics and prosthetics section.

How to Submit Prior Authorization Requests and Operational Routing

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (sign in at UHCprovider.com with a One Healthcare ID). Requests may also be submitted by phone or fax using the numbers on the member's ID card or the operational contact numbers. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Online: Prior Authorization and Notification tool at UHCprovider.com (sign in with One Healthcare ID).
Phone/fax: use numbers on the member's health plan ID card or operational call centers listed elsewhere in this document.

Prior Authorization

Behavioral health prior authorization routing

Behavioral health services (including mental health, substance use disorder care, and applied behavior analysis) are administered through the designated behavioral health network and require routing to Optum Behavioral Health for prior authorization and referrals. For specific codes and authorization routing, call the behavioral health intake number or the number on the member's ID card.

Policy Definitions and Notes

Definition of Prior authorization

DefinitionPrior authorization is the process by which providers request approval from the health plan before performing certain procedures or services; it is not required for emergency or urgent care.

ApplicabilityApplies to inpatient and outpatient services for Mississippi CHIP members provided by network and out-of-network providers (out-of-network must request PA for all procedures).

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool, by phone (877-842-3210), or by fax (888-310-6858).

Optum Behavioral Health

Designated behavioral health networkBehavioral health services are routed through Optum Behavioral Health for prior authorization and referral.

Contact for specific codes

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Mississippi Children's Health Insurance Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

On This Page

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

Orthotics/prosthetics prior auth threshold

Orthotics/prosthetics PA thresholdRetail purchase or cumulative rental cost greater than $500 requires prior authorization for orthotics and prosthetics listed.

Associated L-codesSpecific orthotics/prosthetics L-codes are listed in the orthognathic/orthotics section and subject to the threshold.

Orthognathic contextPrior authorization references appear in the orthognathic surgery section describing the same cost threshold for listed items.

Diagnosis-limited prior auth for standard radiation therapy

Diagnosis-limited PA for standard radiation therapyPrior authorization for standard radiation therapy CPTs is required only when obtained with oncology diagnosis codes in ranges such as C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52.

ScopeApplies to standard (2D/3D) radiation therapy entries where prior auth is conditional on listed cancer diagnosis code ranges.

Related CPTsStandard radiation therapy CPTs (examples in the radiation therapy section) are subject to this diagnosis-limited rule.

Behavioral health prior authorization and referrals: routed through Optum Behavioral Health.

Behavioral health contact: 877-743-8734 (or number on the member's ID card).

Applied Behavior Analysis (ABA): submit per Optum/Provider Express instructions (fax or Provider Express as applicable).

Prior Authorization

CPT/HCPCS codes referenced for prior authorization (partial)

The following CPT codes are specifically referenced multiple times in this document as requiring prior authorization for breast reconstruction and related services. Ensure prior authorization is obtained when billing these codes as indicated.

CPT codes referenced: 19367, 19368, 19369, 19370

Note

Prior authorization not required for listed diagnosis-code + procedure-code combinations

Certain diagnosis-code plus procedure-code combinations do not require prior authorization when billed together. Verify coding pairs before submitting an authorization to avoid unnecessary prior authorization requests.

Examples of diagnosis + procedure pairs NOT requiring prior authorization when billed together: C44.1021 with 67921, 67950, Q2026; C44.1022 with 67922, 67961, Q2026; C44.1091 with 67923, 67966, Q2026; C44.111 with 67921, 67950, Q2026; C44.1121 with 67922, 67961, Q2026; C44.1122 with 67923, 67966, Q2026; C44.1191 with 67917, 67924, Q2026; C44.1192 with 67921, 67950, Q2026; (and additional similar mappings listed in the source).
Confirm exact diagnosis and procedure codes match the allowed combinations before bypassing prior authorization.

Prior Authorization

FAI (Femoroacetabular impingement) prior authorization

Procedures for femoroacetabular impingement syndrome (FAI) require prior authorization. Obtain authorization before scheduling or performing these procedures.

FAI CPT codes requiring prior authorization: 29914, 29915, 29916

Prior Authorization

J0897 prior authorization note

Code J0897 (denosumab for certain indications) requires a special prior authorization note: prior authorization is required when billed for non-oncology diagnoses. Verify diagnosis and obtain authorization accordingly.

J0897: prior authorization required for non-oncology diagnoses.

Prior Authorization

Site of Service prior authorization rules

Site-of-service rules affect prior authorization requirements. Prior authorization is required for services when requested in an outpatient hospital setting unless the same service is performed at a participating Ambulatory Surgery Center (ASC), in which case prior authorization may not be required. Verify site of service when requesting authorization.

Prior authorization required for services requested in an outpatient hospital setting unless performed at a participating ASC.
Examples listed under Site of Service include outpatient hospital codes (36590, 36832) and many surgical procedures; check the site-specific guidance in this policy before scheduling.

Prior Authorization

Sleep apnea procedures and sleep studies - prior authorization

Sleep apnea surgical procedures and sleep studies require prior authorization. Obtain authorization for both surgical interventions for obstructive sleep apnea and for diagnostic sleep testing prior to service.

Sleep apnea procedures requiring prior authorization include maxillomandibular advancement and oral–pharyngeal tissue reduction codes: 21685, 41599, 42145 (and related procedure codes).
Sleep studies requiring prior authorization: 95805, 95807, 95808, 95810, 95811 (and related polysomnography codes).

Prior Authorization

Stimulators and neurostimulators - prior authorization

Implantable stimulators, neurostimulators, and related device procedures require prior authorization. This includes surgically implanted devices that send electrical impulses as well as bone growth stimulators. A broad set of CPT and HCPCS codes for stimulators and neurostimulators are subject to prior authorization; consult the list and obtain authorization before implantation.

Stimulator device codes include bone growth stimulator codes (e.g., 20975, 20979) and HCPCS device codes (E0747, E0748, E0749, E0760).
Neurostimulator CPT codes requiring prior authorization include: 43648, 43881, 43882, 61863, 61864, 61867, 61868, 61885, 61886, 63650, 63655, 63685, 64553, 64555, 64568, 64570 and others listed in the source.
Some device HCPCS (Q2055, Q2056, Q2055/Q2056) and Q-codes are also listed and require authorization.
Gene therapy / transplant-related items and certain code 38232 have specific oncology-only or Optum Transplant routing notes — see policy for those exceptions.

Prior Authorization

Wound vac prior authorization

Negative pressure wound therapy (wound vac) requires prior authorization and is managed through the VAD Case Management team. Contact the VAD Case Management team to obtain prior authorization and guidance on billing codes.

Wound vac prior authorization contact: VAD Case Management team at 855-282-8929.
Example HCPCS code: E2402 (and other wound vacuum-related codes listed in the source).

For specific mental health and substance use codes requiring prior authorization call 877-743-8734 or use the number on the member's ID card.

ABA submissionsApplied behavior analysis (ABA) therapy submissions are via fax or Provider Express as specified by the behavioral health routing instructions.

How to obtain prior authorization (referenced)

Reference to obtaining prior authorizationThe document repeatedly references 'how to obtain prior authorization' and directs providers to submit requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone to the listed numbers.

Portal instructionSign in to UHCprovider.com, select the Prior Authorization and Notification tool/tile on the dashboard to submit online requests.

Phone alternativesPhone numbers (e.g., 866-889-8054 or other specialty numbers listed) are provided as alternate submission routes in the referenced instructions.

Chemotherapy injectables

Chemotherapy injectable drugs groupInjectable chemotherapy drugs (J9000–J9999) administered in an outpatient cancer setting require prior authorization.

Supportive agent examplesIncludes leucovorin (J0640), levoleucovorin (J0641), Lupron Depot (J1950) and other Q-coded or miscellaneous HCPCS chemotherapy injectables.

Submission routeRequests for these agents should be submitted via the Prior Authorization and Notification tool on UHCprovider.com or by the phone numbers provided.

Cancer supportive care agents

Cancer supportive care agentsCancer supportive care agents requiring prior authorization include colony-stimulating factors (e.g., filgrastim, eflapegrastim, pegfilgrastim), erythropoiesis-stimulating agents, certain anti-emetics, and bone-modifying agents (e.g., denosumab).

Representative HCPCS/J-codesExamples listed include J1449, J2506, J0885 and various Q-codes for filgrastim and pegfilgrastim products.

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

DME

DME definition and contextDurable medical equipment (DME) entries list HCPCS codes and require prior authorization when retail purchase or cumulative rental cost exceeds $500 for the listed codes.

Examples of HCPCS/DME codesMany E-, V-, A-, B- and K-codes (e.g., E0266, E0670, V2786, B4152) are enumerated in the DME sections as subject to authorization when over the threshold.

Prosthetics noteThe DME section explicitly states prosthetics are not considered DME for prior authorization purposes.

Prosthetics

Prosthetics exclusion from DMEProsthetics are explicitly not considered DME for prior authorization; see the Orthotics and prosthetics section for separate handling.

Orthotics handled separatelyOrthotics and prosthetics have their own PA rules (including the $500 purchase/rental threshold for PA) distinct from DME listings.

Cross-referenceSee orthotics/prosthetics L-code listings in the orthognathic/orthotics section for codes subject to their PA rules.

DME / HCPCS listing

DME / HCPCS listing practiceDME entries list specific HCPCS codes (E-, V-, A-, B- series and others) with prior authorization instructions tied to the $500 threshold.

ExamplesListed HCPCS examples include A6549, B4152, E0266, E0328, E0460 and numerous E- and V-codes across the DME sections.

Authorization triggerThe presence of a listed HCPCS code plus retail purchase or cumulative rental cost over $500 triggers the prior authorization requirement.

Experimental/investigational

Experimental/investigational servicesExperimental and investigational services (and linked services) require prior authorization; multiple CPT/HCPCS/S codes are listed as examples.

Code examplesExamples include CPT codes 36514, 64722, 65765 and HCPCS codes A4226, A4638, A6000 among others listed in the experimental/investigational section.

PA requirementPrior authorization is required for these services before scheduling or performing them.

Genetic/molecular testing

Genetic/molecular testing requires PAGenetic and molecular testing, including BRCA gene testing, requires prior authorization and is performed in an outpatient setting.

Representative CPT codesListed examples include CPT codes 81162, 81163, 81164, 81228, 81400–81408 and additional molecular test codes.

Procedure detailThe prior authorization process for genetic testing may require specifying the requesting laboratory and other information as noted in the testing section.

prior authorization requirement

Prior authorization required statementPrior authorization is required for genetic/molecular testing (including BRCA) and for listed procedures such as Functional Endoscopic Sinus Surgery (FESS); details reference outpatient setting requirements.

FESS exampleFESS CPT codes (31240, 31253–31259, 31267, 31276, 31287, 31288) are listed as requiring prior authorization.

FAI exampleFemoroacetabular impingement (FAI) procedures (e.g., 29914–29916) also require prior authorization as listed.

home health care prior authorization

Home health care PA requirementHome health care services require prior authorization only in outpatient settings, including when provided in the member's home.

Examples of service codesThe home health care entries reference codes such as G0299, G0300 and S9474 in association with PA requirements.

ScopeThis PA requirement applies to outpatient/home-delivered home health services rather than inpatient care.

Review at Launch for New to Market Medications

Review at Launch referenceThe policy references a 'Review at Launch for New to Market Medications' process and recommends predetermination for drugs on that list.

Where to checkProviders are instructed to check the Review at Launch Medication List for the most up-to-date information on newly FDA-approved drugs.

PA recommendationPredetermination (prior authorization) is highly recommended for drugs included on the Review at Launch list.

Proton Beam

Proton Beam definitionProton Beam is defined as focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Associated CPTsProton beam CPT examples in the radiation therapy section include 77520, 77522, 77523 and 77525.

ContextProton Beam is listed under the Radiation Therapy section where prior authorization rules are described.

Sleep studies

Sleep studies CPT rangeSleep studies referenced for prior authorization include CPT 95805–95811.

Sleep surgery examplesSleep surgery examples requiring PA include maxillomandibular advancement (21685) and other listed codes.

PA requirementSleep studies and select sleep surgeries are identified as requiring prior authorization.

Transplant/CAR T prior authorization contact

Transplant/CAR T contactFor transplant and CAR T-cell therapy services, providers must call the UnitedHealthcare Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the member's ID card.

PA requirementThese services require prior authorization and notification to the transplant case management team.

ExamplesListed therapies include Abecma, Breyanzi, Kymriah, Tecartus and Yescarta among other CAR T and transplant therapies.

38232 conditional PA

38232 conditional PACPT code 38232 requires prior authorization only for an oncology diagnosis.

ContextThis conditional rule is noted in the neurostimulator/gene therapy section and applies specifically to code 38232.

ImplicationProviders should obtain PA for 38232 only when billed with oncology diagnoses; otherwise PA is not required per this note.

Gene therapy PA routing

Gene therapy PA routingCertain gene therapies (Amtagvi, Casgevy, Lantidra, Lenmeldy, Spevigo, Zynteglo) require prior authorization routed through Optum Transplant.

Routing instructionProviders must route PA requests for these listed gene therapies via Optum Transplant as specified in the document.

Associated noteThis routing requirement appears alongside the neurostimulator and gene therapy entries in the clinical services section.