CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Pennsylvania CHIP Medicaid

Lists prior authorization requirements and submission methods for participating providers in UnitedHealthcare Community Plan Pennsylvania CHIP for inpatient and outpatient services; applies to providers and out-of-network providers (excludes emergency/urgent care).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, 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 submission method

800-600-9007phone (PA CHIP prior auth)

877-310-3826fax (prior auth)

$500DME purchase threshold

Severalexamples of required PA services

Services and Code Categories Requiring Prior Authorization

Pennsylvania CHIP prior authorization criteria (partial — document continues)

Prior authorization is required for many specified services and codes in Pennsylvania CHIP; emergency/urgent care is exempt.

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

Prior authorization is not required for emergency or urgent care.

Colony-stimulating factors, certain antiemetics, bone-modifying agents and erythropoiesis-stimulating agents administered in an outpatient setting for a cancer diagnosis require prior authorization; specific J-/Q-codes are listed in the document.

Cardiology: outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiograms require prior authorization; see cardiology resources or call 866-889-8054.

Explicit prior authorization criteria in excerpt

Selected services with explicit prior authorization stance or notes in this excerpt:

Inpatient video cerebral seizure monitoring requires prior authorization.

Injectable chemotherapy drugs (including J9000-J9999, Leucovorin J0640, Levoleucovorin J0641/J0642, Lupron Depot J1950, Q-codes and miscellaneous HCPCS-billed oncology injectables) require prior authorization for outpatient administration for cancer diagnoses; submit requests via the UHC provider portal.

Cochlear and other auditory implants require prior authorization (example codes: 69710, 69714, 69930, L8614, L8619, L8690-L8692).

Continuous glucose monitors require prior authorization when used with a Type 2 diabetes diagnosis (example codes: A4226, A4239, A9276, A9277).

Prior authorization criteria (partial)

Prior authorization required for listed services or when thresholds are met

Durable medical equipment (DME): prior authorization required only for codes listed with a retail purchase or cumulative rental cost of more than $500.

Enteral and in‑home nutritional therapy codes listed (examples: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153) require prior authorization.

Functional endoscopic sinus surgery (FESS) procedures (examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288) require prior authorization.

Gender dysphoria procedures and related services require prior authorization (examples: CPT 55970, 55980 and ICD-10 codes F64.0, F64.1, F64.2, F64.8, F64.9).

Prior authorization/notification listing

Listed services require prior authorization or notification as noted.

Genetic and molecular testing performed in an outpatient setting requires prior authorization; multiple U-codes and molecular test codes are listed.

Home health services require prior authorization when provided in outpatient settings or in the member's home (example codes: G0156, G0162, G0299, G0300, G0493-G0496, S9122-S9124, S9474).

Hospice services require prior authorization (example code: T2045).

Injectable medications: multiple J-/Q- codes require prior authorization; submit via the Provider Portal (examples listed in document).

Prior authorization requirements (listed services)

Services and codes requiring prior authorization/notification as listed below.

Injectable medications: Multiple injectable medications (examples include J7211, J0879, J2507, J0217, J1932, J0202, J0174, J1306, J2778, J0221, J1950, J9217, J3399, etc.) require prior authorization; submit requests via the Provider Portal or call 888-397-8129.

Inpatient admissions: Prior authorization and notification of admission date required for the following facility types: Acute care hospitals; Acute inpatient rehabilitation; Critical access hospitals; Long-term acute care hospitals; Skilled nursing facilities.

Joint replacement: Total hip and knee replacement procedures and related CPT/HCPCS codes (examples listed across chunks 105-106) require prior authorization.

Non-emergent air ambulance transports require prior authorization (examples: A0430, A0431, A0435, A0436, S9960, S9961).

Prior authorization requirements

Prior authorization stance and instructions for listed services and codes.

Prior authorization is required for the listed CPT/HCPCS codes and services, including orthotics/prosthetics L-codes, private duty nursing T-codes, proton beam therapy CPT codes, and advanced outpatient imaging procedures; follow the submission instructions in this document.

Prior authorization and notification criteria (excerpt)

Services in the listed categories require prior authorization or notification as indicated; providers must contact the phone number or use the portal to request authorization.

Advanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures): care providers ordering these procedures must provide notification prior to scheduling; request prior authorization by calling 866-889-8054 or via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Proton beam therapy (CPT 77520, 77522, 77523, 77525) requires prior authorization.

Rhinoplasty and septoplasty procedures (CPT ranges 30400-30435, 30410, 30420, 30430-30462) require prior authorization.

Site-of-service guidance: prior authorization is required only when requesting a service in an outpatient hospital setting; it is not required if performed at a participating ambulatory facility.

Sleep apnea procedures and surgeries require prior authorization (codes and examples listed in document).

Prior authorization and operational instructions

Coverage stance in this section is operational: many specific procedures and device codes require prior authorization; contact instructions provided where applicable.

Numerous procedures and device implantations listed (examples: sleep apnea surgeries, spinal surgeries, stimulators, transplants/CAR T-cell therapy, ventricular assist devices, wound vac) require prior authorization prior to service.

Transplant and CAR T-cell therapy workflow: For transplant and CAR T-cell therapy services (including listed products), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member ID card to obtain prior authorization.

VAD workflow: For ventricular assist device (VAD) services, call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD team; prior authorization is required (example CPT codes: 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982).

Neurostimulator and other implantable stimulators (CPT and HCPCS codes shown, e.g., 64553, 64555, 64568, 64570, 64590, L8680, L8682, L8685, L8686-L8688) require prior authorization.

CPT / HCPCS / ICD-10 Codes Referenced

Cancer supportive care - Injectable antiemetics & CSFsHCPCSCovered

J1453	Fosaprepitant, 1 mg (Emend for Injection)
J1456	Fosaprepitant (Teva)
J1454	Fosnetupitant 235 mg and palonosetron 0.25 mg
J1627	Granisetron, extended-release
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)

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Cardiovascular - ICD-10 diagnostic series referencedICD-10Covered

I70.*	Atherosclerosis and related arterial embolism/thrombosis series (multiple specific I70.x entries listed)
I72.*	Other aneurysm of peripheral vessels series
I74.*	Arterial embolism and thrombosis series
I75.*	Atheroembolism and related specified codes
I77.*	Other disorders of arteries and arterioles series
T82.*	Complications of cardiac and vascular devices, implants and grafts series
S81.*	Open wound, knee and lower leg series (trauma codes listed)
S91.*	Open wound, ankle and foot series (trauma codes listed)

Neurodiagnostic - EEG/Seizure monitoring CPT rangeCPTCovered

95700-95718	Cerebral seizure monitoring and related inpatient/outpatient video EEG codes (95700 and 95711-95718 series)
95722-95726	Electroencephalogram (EEG) monitoring codes 95722, 95724, 95726 etc.

Neurodiagnostic - Representative CPT codesCPTCovered

95700	Initial cerebral seizure monitoring
95711	Cerebral seizure monitoring
95712	Cerebral seizure monitoring
95713	Cerebral seizure monitoring
95714	Inpatient video EEG
95715	Inpatient video EEG
95716	Inpatient video EEG
95718	Inpatient video EEG
95722	EEG routine
95724	EEG with additional leads

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Durable Medical Equipment - CGM and suppliesHCPCSCovered

A4226	Continuous glucose monitoring transmitter
A4239	Continuous glucose monitor receiver
A9276	Continuous glucose monitor supplies
A9277	Continuous glucose monitor supplies

DME - sample device & thresholdsHCPCSCovered

A9279	Misc DME code referenced
A9280	Misc DME code referenced
A9900	Miscellaneous DME

Orthotics / Prosthetics - sample codesHCPCSCovered

L0112	Orthotic - sample code
L0170	Orthotic - sample code
L0456	Orthotic - sample code
L0462	Orthotic - sample code
L0464	Orthotic - sample code

Orthotics/Prosthetics - prior auth threshold notemixed

Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost threshold per policy (preserve existing thresholds).

Surgical - Reconstructive example codesCPTCovered

21230-21295	Facial bone reconstruction codes range (mandible/maxilla-related procedures)
21740	Reconstructive procedure of facial bones
28344	Foot/ankle reconstructive code example
30620	Rhinoplasty/reconstructive nasal procedure requiring prior authorization
67900-67966	Eyelid/ptosis/reconstructive oculoplastic procedure range

Reconstructive procedure codes - detailed examplesCPTCovered

30620	Reconstructive procedure of the nose (example)
67900	Repair of eyelid laceration/lesion - reconstructive series start
67901	Eyelid procedure
67902	Eyelid procedure
67903	Eyelid procedure
67904	Eyelid procedure
67906	Eyelid procedure
67908	Eyelid procedure
67909	Eyelid procedure
67911	Eyelid procedure

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ICD-10 mapping entries (selected series)ICD-10Covered

I70.*	Extensive list of I70.x atherosclerosis-related codes included throughout the cardiovascular section (multiple specific subcodes listed in source).
I72.*	Peripheral aneurysm codes (I72.3, I72.4, I72.8, I72.9 referenced).
I74.*	Arterial embolism/thrombosis codes (I74.3, I74.4, I74.5, I74.8, I74.9 referenced).
I75.*	Atheroembolism/other ischemic codes (I75.021-I75.029 and I75.89 referenced).
I77.*	Other disorders of arteries and arterioles (I77.2, I77.70, I77.72, I77.77, I77.79 referenced).
T82.*	Complications of cardiac and vascular devices (T82.818A, T82.868A referenced).
S81.*	Lower leg/knee wound/trauma codes (S81.801A, S81.802A, S81.809A referenced).
S91.*	Ankle/foot wound/trauma codes (S91.301A, S91.302A, S91.309A referenced).

How Providers Submit Requests and Operational Notes

Prior Authorization

Submission methods and emergency care exception

To request prior authorization, submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com), or by phone at 800-600-9007 or fax at 877-310-3826. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services except emergent/urgent care.

Prior Authorization

Categories requiring prior authorization

The document lists multiple specific service categories that require prior authorization (examples include abortion, bariatric surgery, behavioral health services, bone growth stimulators, BRCA genetic testing, breast reconstruction/mastectomy and cancer supportive care); CPT/HCPCS codes for each category are provided in the policy.

Definitions and Terminology

inv-71: Prior authorization

DefinitionA requirement that providers submit approval requests before performing certain procedures or services, except for emergency or urgent care.

Submission methodsRequests may be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone (800-600-9007), or by fax (877-310-3826).

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

inv-72: Participating and out-of-network providers

Participating providersParticipating care providers must follow the listed prior authorization requirements in this document.

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.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Pennsylvania CHIP Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateN/A

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

SourceLink

On This Page

Orthognathic/maxillofacial surgery: Orthognathic and maxillofacial/jaw functional impairment procedures (multiple 21xxx CPT codes listed) require prior authorization.

Orthotics and prosthetics codes listed (examples include L0112, L0170) require prior authorization only when retail purchase or cumulative rental cost meets the stated threshold.

Spinal surgery requires prior authorization (codes and examples listed in document).

Wound vacuum therapy (example HCPCS E2402) requires prior authorization.

Prior Authorization

Cardiology prior authorization instructions

Cardiology outpatient and office-based diagnostic catheterizations, electrophysiology implants and stress echocardiograms require prior authorization; providers may submit requests via the Provider Portal or call 866-889-8054 and visit UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for details and codes.

Prior Authorization

Chemotherapy prior authorization instructions

Injectable chemotherapy drugs require prior authorization (including J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642 and Lupron Depot J1950, Q-codes and miscellaneous oncology injectables); submit requests online via the Prior Authorization and Notification tool on UHCprovider.com.

Prior Authorization

Cerebral seizure monitoring PA

Inpatient cerebral seizure (video) monitoring requires prior authorization when performed inpatient.

Codes referenced include 95700–95718 and 95722–95726 (EEG/video monitoring range).

Prior Authorization

Cochlear implants PA

Cochlear implants and other auditory implants require prior authorization; the policy lists device and procedure codes including 69710, 69714, 69930 and HCPCS L8614, L8619, L8690–L8692.

Prior Authorization

CGM prior authorization

Continuous glucose monitors (CGMs) require prior authorization when used with a Type 2 diabetes diagnosis; listed device codes include A4226, A4239, A9276 and A9277.

Prior Authorization

DME prior authorization note

Prior authorization for durable medical equipment is required only for codes listed with a retail purchase or cumulative rental cost of more than $500; the policy notes that prosthetics are not DME.

Examples of DME codes shown: A9279, E0471; threshold noted as $500 purchase or cumulative rental cost.

Prior Authorization

Enteral/In-home nutritional therapy prior authorization

Enteral and in‑home nutritional therapy services require prior authorization; the policy lists enteral/home nutrition HCPCS codes such as B4034, B4035, B4036, B4100 and related B‑codes.

Prior Authorization

Femoroacetabular impingement prior authorization

Treatment for femoroacetabular impingement syndrome requires prior authorization for the listed procedure code(s), including CPT 29916.

Prior Authorization

FESS prior authorization

Functional endoscopic sinus surgery (FESS) codes require prior authorization; the policy lists CPT codes such as 31240, 31253–31259, 31267, 31276, 31287 and 31288.

Prior Authorization

Gender dysphoria prior authorization

Gender dysphoria–related procedures and services require prior authorization; listed procedural codes include 55970 and 55980 and ICD‑10 diagnosis codes F64.0–F64.9 and Z87.890 where noted.

Prior Authorization

Experimental/investigational codes

Examples of services and codes designated experimental or investigational require prior authorization; the document lists sample codes such as 33477, 36514, 64722, 65765, 66180 and HCPCS codes A4638, A6000, A9274.

Prior Authorization

Genetic/molecular testing prior authorization

Genetic and molecular testing requires prior authorization; the policy lists numerous U‑codes (for example 0018U, 0022U, 0023U, 0055U, 0060U, 0129U, 0171U, 0173U, 0179U, 0214U) and notes notification/prior authorization is required before BRCA sequencing is performed.

Ordering provider must notify the laboratory and the laboratory will notify UnitedHealthcare for BRCA testing.

Prior Authorization

Home health prior authorization

Home health services require prior authorization when provided in outpatient settings or in the member's home; listed codes include G0156, G0162, G0299, G0300 and related G/S codes.

Prior Authorization

Hospice prior authorization

Hospice services require prior authorization; the policy lists T2045 for hospice-related prior authorization.

Prior Authorization

Injectable medications prior authorization

Multiple injectable medications are listed that require prior authorization; providers should submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool per the policy.

Examples of J‑/Q‑codes listed in the policy (non‑exhaustive).
For certain products/unclassified codes the policy includes product‑specific PA rules (see chunk 104).

Prior Authorization

Prior authorization entries (partial)

The policy includes multiple individual injectable medication entries (e.g., Kanuma J2840 referenced repeatedly); follow the listed HCPCS/J‑code entries and submit PA requests per the Provider Portal instructions.

Prior Authorization

Prior authorization entries (partial)

Additional prior authorization entry fragments reference branded products (e.g., Koate, Hemofil M.) in association with CPT/HCPCS codes; follow the HCPCS/J‑code listings in the policy and submit PA requests via the Provider Portal.

Prior Authorization

Prior authorization for injectable medications

For the injectable medications listed in the policy (multiple J‑ and Q‑codes), submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129; note that some unclassified/temporary codes (C9159, J3490, J3590) and certain products have product‑specific PA requirements described in the policy.

Call 888-397-8129 as an alternative contact for injectable medication PA requests.
Certain unclassified/temporary codes require PA only for specific products (policy lists exceptions).

Prior Authorization

Inpatient admission prior authorization/notification

Inpatient admissions to listed facility types providing post‑acute inpatient services require prior authorization and notification of the admission date; facility types include acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals and skilled nursing facilities.

Prior Authorization

Joint replacement prior authorization

Total joint replacement procedures (hip and knee) require prior authorization; the policy lists associated CPT/HCPCS codes (examples include codes in the 271xx, 274xx and related ranges).

Prior Authorization

Non-emergent air ambulance prior authorization

Non‑emergent air ambulance transports require prior authorization; listed transport codes include A0430, A0431, A0435, A0436 and related S‑codes.

Prior Authorization

Orthognathic/maxillofacial surgery prior authorization

Orthognathic and maxillofacial (jaw functional impairment) procedures require prior authorization; the policy lists numerous CPT codes in the 21xxx series (for example 21121, 21123, 21125, 21127 and many others).

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics require prior authorization only for the codes listed with a retail purchase or cumulative rental cost threshold; the policy provides numerous L‑codes (for example L0112, L0170, L8042–L8047 and others) and notes prosthetics are not DME.

PA required when retail purchase or cumulative rental cost meets the policy threshold (document references $500 for DME elsewhere).

Prior Authorization

Radiology prior authorization and notification instructions

Care providers ordering advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) are responsible for providing notification prior to scheduling; to request prior authorization call 866-889-8054 or submit requests via the Prior Authorization and Notification tool on UHCprovider.com. Visit UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Radiology Prior for details and CPT codes.

Phone contact for radiology prior authorization: 866-889-8054.

Prior Authorization

Orthotics and prosthetics prior authorization requirement

The policy reiterates that orthotics and prosthetics L‑codes listed require prior authorization when the retail purchase or cumulative rental cost reaches the policy’s threshold and provides many specific L‑codes requiring PA.

Prior Authorization

Other services requiring prior authorization

The policy lists other services that require prior authorization, including proton beam therapy (CPT 77520, 77522, 77523, 77525) and certain prostate procedures; follow the listed CPT/HCPCS codes and submission instructions.

Proton beam therapy CPT codes: 77520, 77522, 77523, 77525.

Prior Authorization

Radiology prior authorization contact and portal

For radiology prior authorization or notification, providers should call 866-889-8054 or submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com); additional radiology resources and CPT lists are available at UHCprovider.com/PAcommunityplan.

Prior Authorization

Procedure-specific prior authorization notes

Procedure‑specific PA notes include proton beam therapy CPT codes (77520, 77522, 77523, 77525) and examples of prostate procedures requiring PA (e.g., CPT 37243, 52441, 55866); follow the listed CPT codes and submission instructions in the policy.

Prior Authorization

ENT, sleep apnea, spinal surgery prior authorization

ENT procedures (rhinoplasty/septoplasty ranges 30400–30435, 30410, 30420, 30430–30462), sleep apnea procedures and many spinal surgeries require prior authorization; site‑of‑service guidance notes PA is required only when requesting the service in an outpatient hospital setting (not required if performed at a participating Ambulatory).

Rhinoplasty/septoplasty CPT ranges: 30400–30435 and 30430–30462.
Site of service: PA required when requesting service in outpatient hospital setting; not required if at a participating Ambulatory.

Prior Authorization

Site of service prior authorization guidance

Site‑of‑service guidance: prior authorization is required only when requesting services in an outpatient hospital setting; prior authorization is not required if the service is performed at a participating Ambulatory, per the policy.

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures and surgeries require prior authorization; the policy lists related CPT/HCPCS codes and instructs providers to follow PA submission procedures.

Prior Authorization

Spinal and other surgeries prior authorization

A broad set of spinal and other surgical CPT/HCPCS codes require prior authorization; the policy provides extensive CPT listings (e.g., 22100, 22101, 22102, 22110, 22112 and many more) and requires obtaining PA per the document instructions.

Prior Authorization

Transplant and CAR T-cell therapy prior authorization

Transplant and CAR T‑cell therapy services require prior authorization and a specific contact: call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the member ID card to initiate authorization.

Contact number for transplant/CAR T services: 888-936-7246.

Prior Authorization

VAD prior authorization and workflow

Ventricular assist devices (VAD) require prior authorization; the policy instructs providers to call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD team.

Example VAD CPT codes listed include 33927–33982 in the policy.

Prior Authorization

Neurostimulator/stimulator devices prior authorization

Implantation of neurostimulators and related stimulators requires prior authorization; the policy lists CPT/HCPCS codes including 64553, 64555, 64568, 64570 and device HCPCS L8680–L8688 and E0747–E0760.

Prior Authorization

Wound vac prior authorization

Negative-pressure wound therapy (wound vac) requires prior authorization; the policy lists E2402 as a wound vac HCPCS code requiring PA.

ExceptionEmergency and urgent care are exempt from prior authorization for both participating and out-of-network providers when emergent/urgent.

inv-73: UHCprovider.com portal submission

Portal toolUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) to submit PA requests.

Radiology-specific resourcesFor advanced outpatient imaging prior authorization and resources, visit UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Radiology Prior.

Alternative contactRadiology PA may also be requested by calling 866-889-8054 (as noted for advanced imaging).

inv-74: Cochlear implant codes

CodesCochlear implant CPT/HCPCS codes listed include 69710, 69714, 69930 and HCPCS L8614, L8619.

RequirementCochlear implants and other auditory implants require prior authorization.

Device descriptionL8614/L8619 referenced as internal/external auditory implant device codes in the cochlear implant section.

inv-75: Prosthetics vs DME

StatementProsthetics are not considered durable medical equipment (DME).

ImplicationOrthotics/prosthetics follow their own PA rules (e.g., PA tied to retail purchase/cumulative rental cost thresholds), distinct from general DME rules.

Related codesDME codes (e.g., A9279, E0471) are listed separately from prosthetics L-codes in the document.

inv-76: Experimental/Investigational

MeaningServices or codes marked 'Experimental and investigational' require prior authorization as indicated in the document.

ExamplesDocument lists example CPT/HCPCS codes under experimental/investigational such as 33477, 36514, 64722 and others.

Provider actionObtain prior authorization before scheduling services labeled experimental/investigational.

inv-77: Prior authorization/Notification

General ruleCertain services explicitly require prior authorization or notification as listed (e.g., genetic/molecular testing, home health in outpatient settings).

Genetic testingPrior authorization required for listed U-codes and molecular/genetic tests; BRCA testing requires notification/prior authorization before DNA sequencing.

Home healthHome health services require prior authorization when provided in outpatient settings or in the member's home.

inv-78: Injectable medications (prior auth)

RuleMultiple injectable medications (listed by J-/Q-codes) require prior authorization; submit requests via the Provider Portal or specified phone numbers.

Example products/codesExamples include Actemra (J3262), J7183 (Wilate), J1558 (Xembify), J0218 (Xenpozyme), J3399 (Zolgensma) and many others listed in the injectable medications sections.

Special handlingUnclassified/temporary codes (e.g., C9159, J3490, J3590) may require PA only for specific products; see injectable medications section for exceptions.

inv-79: Kanuma®

Product-code mappingKanuma® is referenced in association with HCPCS J2840 in the document.

PA instructionKanuma® (J2840) appears in the injectable medications listing and requires prior authorization per the listed procedure for injectables.

RepetitionThe document contains multiple repeated references to Kanuma® J2840 in the injectable medications section.

inv-80: Koate, Hemofil M.

Product referencesKoate and Hemofil M. are product/brand names repeatedly referenced in association with CPT/HCPCS codes in the document.

ContextThese product mentions appear in sections listing injectable products and associated PA instructions.

ActionCheck the injectable medications section for PA requirements when billing for these products.

inv-81: Prior authorization

DefinitionPrior authorization is the process to obtain approval before performing specified services; providers must follow submission methods outlined in the document.

Submission optionsOnline via Provider Portal, phone (800-600-9007 or other specialty numbers) or fax as indicated for service type.

Exceptions/notesCertain services (e.g., radiology) have specialty phone numbers and web resources noted for PA requests.

inv-82: Inpatient admission notification

RequirementNotification (and in some cases prior authorization) of the admission date is required for inpatient admissions to listed facility types providing post-acute inpatient services.

Affected facility typesAcute care hospitals; Acute inpatient rehabilitation; Critical access hospitals; Long-term acute care hospitals; Skilled nursing facilities.

How to notifyFollow the prior authorization and notification instructions in the inpatient admission section (Provider Portal or phone where specified).

inv-83: Proton beam therapy

RequirementProton beam therapy requires prior authorization.

CPT codes77520, 77522, 77523, 77525 are the proton beam therapy CPT codes listed.

Provider actionObtain prior authorization prior to scheduling proton beam therapy per document instructions (Portal/phone).

inv-84: Advanced outpatient imaging

ScopeAdvanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) require notification/prior authorization as specified.

How to requestCall 866-889-8054 or submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

ResourcesFor detailed CPT codes requiring PA, visit UHCprovider.com/PAcommunityplan > Prior Authorization and Notification Resources > Radiology Prior.

inv-85: Stimulators / Implantation of device

RequirementImplantation of stimulators (neurostimulators, bone growth stimulators) requires prior authorization.

Example HCPCSE0747, E0748, E0749, E0760 are listed for implantation/device stimulators.

Codes/proceduresAssociated CPT codes (example: 52352, 52353, 52356, 54161) are included in the stimulator/device PA listing.

inv-86: Ventricular assist devices (VAD)

RequirementVentricular assist devices (VAD) require prior authorization.

WorkflowCall the notification number on the back of the member's ID card, then fax the form provided by the nurse to the Optum VAD team.

Example CPT/HCPCS codes33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982 are listed in the VAD section.