Colorado Rocky Mountain Health Plans Prior Auth LTSS | OpenPayer
CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior authorization requirements for Virginia Cardinal Care LTSS
Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) providers; applies to participating in-network and out-of-network providers requesting authorization for inpatient and outpatient services.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective August 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-843-4366.
No material clinical or coverage changes in this revision.
877-843-4366Provider phone number for prior authorization
Online portalOnline submission method
multiplePA required (examples)
J9000-J9999Chemotherapy PA range
$500
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Orthotics threshold
Services Requiring Prior Authorization and Coverage Rules
Behavioral health services — contact number on member ID for specific prior authorization; ABA therapy referrals submitted via fax or Provider (prior authorization process applies where indicated).
Providers must obtain prior authorization before performing services listed above except where the document specifies otherwise (e.g., emergency/urgent care).
See submission methods and contact instructions elsewhere in the policy.
inv-02: Mastectomy coding and prior authorization (informational)
The document lists mastectomy CPT codes and repeatedly references prior authorization; these entries are informational and do not contain additional medical necessity decision criteria in the cited chunks.
Mastectomy CPT codes referenced multiple times — 19368, 19369, 19370, 19371; prior authorization is referenced alongside these codes in the document extracts.
Entries repeat the same CPT codes across multiple lines without additional clinical-entry criteria in these chunks; treat listed codes as requiring standard prior authorization workflow per the policy.
See provider submission instructions for how to request authorization.
inv-03: Cancer supportive care prior authorization requirements
Injectable cancer supportive care medications and related agents require prior authorization as noted; portal submission instructions are provided.
Cardiovascular procedures listed require prior authorization when associated with the specified diagnosis codes and clinical context.
Prior authorization is required for lower extremity angiography and related endovascular interventions; example CPT codes include 37220, 37221, 37224, 37225 (prior authorization required).
Cardiology outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echos require prior authorization per participating physician guidance; submit requests via the provider portal or phone as noted in the policy.
inv-05: Extracted coverage criteria (partial)
Extracted coverage/authorization stances and notable examples from this section:
Prior authorization required for inpatient continuous video EEG monitoring (examples: CPT 95700, 95711–95718, 95720–95726 as listed); prior authorization is not required for outpatient EEG services as noted.
Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting — HCPCS range J9000–J9999 and leucovorin J0640; miscellaneous/unassigned chemotherapy billed under miscellaneous HCPCS codes also require portal submission for prior authorization.
Prior authorization required for cochlear implants and related device codes (examples: CPT 69710, 69714, 69930; HCPCS L8614, L8619, L8690–L8692).
Prior authorization required for continuous glucose monitor supplies when billed with a Type 2 diabetes diagnosis (examples: A4226, A4239, A9276, A9277, A9278, E0787).
Selected covered services and tests in this section require prior authorization; several other items are specifically marked experimental/investigational and also require authorization.
Enteral in‑home nutritional therapy (enteral or gastrostomy tube) requires prior authorization; example HCPCS codes B9002, B9004, B9006, B9998 are listed.
Experimental and investigational procedures and linked services require prior authorization; examples of listed CPT/HCPCS codes include 33477, 36514, 64722, 65765, 66180, A4638, A6000, A9274, E0231, E1831, S1030, S1031, S2102.
Genetic and molecular testing requires prior authorization; representative CPT codes listed include 81162–81164, 81228–81229, 81400–81417 and many others in the molecular/genetic testing series.
Home health care provided in outpatient settings including the member's home requires prior authorization (examples: G0299, G0300, G0493–G0496, S9123, S9124, S9474).
Selected surgeries requiring prior authorization
inv-07: Authorization and code listing notes
Notes on authorization workflow and code listings in this section:
Prior authorization is required for certain home health services and specified outpatient services; when prior authorization is required for injectable medications, providers should submit requests using the Prior Authorization and Notification tool on UHCprovider.com or call the phone number listed (888-397-8129 for injectables in this section).
The presence of enumerated injectable medication HCPCS/J-codes in the list indicates those drugs are subject to prior authorization as described; some unclassified/temporary codes require authorization only for specified drugs (see list).
Provider instruction: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) and follow the portal prompts for miscellaneous/unassigned chemotherapy or injectable medication prior authorization requests.
inv-08: Authorization and coverage criteria (section)
Authorization and coverage rules summarized from this section:
Injectable medications listed (examples: J1558, J0218, J2357, J3399, J1429, J9332, J9334) require prior authorization; predetermination is recommended for drugs on the Review at Launch list; unclassified/temporary codes (C9399, J3490, J3590) require prior authorization only for specified drugs.
Joint, total hip and knee replacement procedures and associated musculoskeletal procedures require prior authorization (multiple CPT codes such as 24360–24363, 24370–24371, 27120, 27125, and many others listed).
Non-emergent air ambulance transport requires prior authorization for specified A0 and S9 codes (e.g., A0430, A0431, A0435, A0436, S9960, S9961).
Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds the referenced threshold (more than $500); many L-codes are enumerated for which prior authorization applies.
inv-09: Coverage criteria for listed services
Radiation therapy and related services require authorization as indicated; some standard 2D/3D therapies require authorization only for certain cancer diagnosis ranges.
Radiation therapy requires prior authorization; example IGRT and IMRT codes listed include 77014, 77387, 77385, 77386 and associated G‑codes (G6001–G6016).
Standard radiation therapy (2D/3D): Standard 2D/3D radiation therapy codes (77401, 77402, 77407, 77412 and related codes) require prior authorization only when billed with diagnosis codes within the specified ranges (C34.00–C34.92, C50.011–C50.929, C61, C79.51–).
Private duty nursing and numerous orthotics/prosthetics L‑codes require prior authorization; prostate procedures and many other listed services also require prior authorization per the section.
inv-10: Prior authorization and notification criteria (partial)
Examples of procedures and services subject to prior authorization and related notification processes (partial list):
Selected surgical and procedural examples (prior authorization required)
Shoulder arthroscopy and shoulder surgeries — example CPT 29805 and related arthroscopic codes (prior authorization required).
Spinal surgery — example CPT 22100 and related spinal surgery CPTs (prior authorization required).
Sleep apnea procedures and related surgeries (prior authorization required) — example CPTs include 21685, 41599, 42145 as listed.
Transplants and CAR T‑cell therapies require prior authorization; contact the transplant/CAR T management team at 888-936-7246 or use the notification number on the member's health plan ID card for authorization/coordination.
Code Lists (CPT/HCPCS/ICD-10) and Coding Notes
Bariatric surgery codesCPTCovered
43644
Bariatric surgery (example code listed)
43775
Bariatric surgery (example code listed)
43645
Bariatric surgery (example code listed)
43842
Bariatric surgery (example code listed)
43659
Bariatric surgery (example code listed)
43845
Bariatric surgery (example code listed)
43770
Bariatric surgery (example code listed)
43846
Bariatric surgery (example code listed)
Bone growth stimulator codesCPTCovered
20975
Bone growth stimulator
20979
Bone growth stimulator
Breast reconstruction/mastectomy codesmixedCovered
19316
Breast reconstruction (non-mastectomy)
19318
Breast reconstruction (non-mastectomy)
19325
Breast reconstruction
19328
Breast reconstruction
19330
Breast reconstruction
19340
Breast reconstruction
19342
Breast reconstruction
19350
Breast reconstruction
19357
Breast reconstruction
19361
Breast reconstruction
1–10 of 19
1/2
Mastectomy CPT codesCPT
19368
Mastectomy (code listed in document)
19369
Mastectomy (code listed in document)
19370
Mastectomy (code listed in document)
19371
Mastectomy (code listed in document)
Cancer supportive care injectable drug codesHCPCSCovered
Radiation therapy and related CPT/HCPCS/G-codesCPT | HCPCS | mixed
77014
Image-guided radiation therapy (IGRT)
77387
Radiation therapy (associated services)
77520
Proton beam (dosimetry/therapy)
77385
IMRT planning/delivery
examples from sectionmixedCovered
30400
Rhinoplasty
30410
Rhinoplasty
30420
Rhinoplasty
30430
Rhinoplasty
29805
Shoulder arthroscopy
22100
Spinal surgery
38208
Hematopoietic progenitor cell transplantation code (listed in mapping block)
E0747
Stimulator HCPCS (example listed)
E0748
Stimulator HCPCS
E0749
Stimulator HCPCS
1–10 of 18
1/2
Chemotherapy outpatient PA threshold
ThresholdInjectable chemotherapy drugs administered in an outpatient setting require prior authorization (HCPCS range J9000–J9999; leucovorin J0640).
ScopeIncludes intravenous and intrathecal outpatient chemotherapy and miscellaneous/unassigned chemotherapy billed under miscellaneous HCPCS codes.
How to Submit Requests, Notifications, and Provider Requirements
Note
Submission methods and general rules
Submit prior authorization and notification requests using the payer's online Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — sign in with One Healthcare ID, then select the Prior Authorization and Notification tab). Phone numbers and specialty contacts may apply per service (see specific procedure entries). 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 on UnitedHealthcare Provider Portal (UHCprovider.com).
Phone numbers and specialty contacts vary by service — use the member ID card number or the portal guidance for the appropriate line.
Prior Authorization
Services requiring prior authorization (examples)
The following services are examples that require prior authorization. This list is not exhaustive — consult the portal or member ID card for plan-specific requirements.
Defined Terms and Short Explanations
Prior authorization (definition & scope)
DefinitionPrior authorization is the process by which providers submit requests to UnitedHealthcare to obtain approval before providing certain services.
Emergency/urgent carePrior authorization is not required for emergency or urgent care.
Submission methodsRequests can be submitted via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (877-843-4366).
ABA therapy referral submission
Referral methodApplied behavior analysis (ABA) therapy referrals should be submitted via fax or Provider as stated in the behavioral health section.
ContextThis instruction appears alongside other behavioral health prior authorization directions; contact the number on the member's ID for code-specific queries.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateEffective August 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 877-843-4366.
Antiemetic codes such as J1456 — prior authorization required as listed.
For many injectable medications (including 'Review at Launch' new-to-market drugs and certain unclassified/temporary codes), predetermination or prior notification is recommended or required as specified; prior notification for Cimzia and Synagis is via Optum Rx (800-310-6826).
Exception: Effective May 1, 2023, codes 14020, 14021 and 14061 do not require prior authorization when billed with designated diagnosis codes (see document for Dx list).
Functional endoscopic sinus surgery (FESS) codes including 31240, 31253–31259, 31267, 31276, 31287, 31288 — prior authorization required.
Hysterectomy — CPT codes 58150, 58152, 58180, 58260 and related CPTs (58262, 58263, 58267, 58270) — prior authorization required.
Ventricular assist devices (VAD) require prior authorization and a notification process: call the notification number on the back of the member's ID card and fax the provided form to the Optum VAD Case Management team at 855-282-8929; example VAD procedure/device codes include 33927, 33975, 33976, 33979, 33981–33983, Q0507–Q0509 as listed.
Vein procedures (e.g., 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766) require prior authorization per the section.
Submission method
Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
DME cost threshold
ThresholdDME items with a purchase or rental cost exceeding $500 (cost of more than $500) trigger prior authorization or additional review.
ScopeApplies to specified HCPCS DME codes (examples include E0466, E0470, E0300, E0328, E0329, E0445).
NotesProsthetics are noted as not DME in this section; some DME entries reference purchase versus rental distinctions.
Therapeutic radiopharmaceuticals codes noted
CodesA9513, A9590, A9696, A9699
Service typeTherapeutic radiopharmaceuticals — listed as requiring prior authorization when applicable.
ContextThese codes are shown alongside other injectable medications and prior authorization instructions; predetermination recommended for new-to-market drugs (Review at Launch).
Orthotics/prosthetics prior auth threshold
ThresholdPrior authorization required for orthotics/prosthetics when retail purchase or cumulative rental cost exceeds $500.
ExamplesApplies to many L-codes listed (e.g., L0486, L0624, L0631, L0632, L0634, L0636, L0637).
ApplicationRequirement applies to both purchase and cumulative rental cost calculations as specified in the orthotics/prosthetics section.
Behavioral health services — call number on member ID card for specific codes; ABA therapy requires submission as directed.
Bone growth stimulators (e.g., CPT/HCPCS 20975, 20979).
Breast reconstruction and mastectomy-related procedures (see mastectomy callout for codes).
Cancer supportive care: injectable chemotherapy and supportive care drugs administered outpatient (J9000–J9999, leucovorin J0640 and listed colony-stimulating factors and other biologics).
Gender dysphoria treatment and related surgical codes (e.g., CPT 55970, 55980 and a list of surgical codes tied to diagnosis codes F64.x) — prior authorization required.
Home health care services (e.g., G0299, G0300, G0493–G0496, S9123–S9125, S9474) — prior authorization required for outpatient/home settings.
Injectable medications and therapeutic radiopharmaceuticals (extensive J- and Q-codes listed) — prior authorization or prior notification required as noted.
Joint replacement and major musculoskeletal procedures (multiple CPT codes) — prior authorization required.
Non-emergent air ambulance transport (e.g., A0430, A0431, A0435, A0436) — prior authorization required.
Orthotics and prosthetics with retail purchase or cumulative rental cost thresholds (L-codes listed) — prior authorization required when retail or rental exceeds thresholds.
Radiation therapy and advanced radiology (IMRT, proton beam, IGRT, certain CT/MRI/PET/nuclear cardiology) — prior authorization/notification required.
Spinal surgery, shoulder surgery, sleep apnea surgeries and other major surgical categories — prior authorization required.
Transplants and CAR T-cell therapy — contact the transplant management team at 888-936-7246 or the notification number on the member's ID card.
Ventricular assist devices (VAD) — prior authorization and specific notification/fax process with Optum VAD Case Management (855-282-8929).
Prior Authorization
Mastectomy procedure codes and prior authorization references
Mastectomy and related reconstruction procedures require prior authorization. Providers should obtain authorization prior to scheduling. The policy lists the commonly used mastectomy and reconstruction CPT codes; examples include: 19368, 19369, 19370, 19371, 19380, 19396 and an array of reconstruction codes (e.g., 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367).
Mastectomy CPT codes include (but are not limited to): 19368, 19369, 19370, 19371.
Breast reconstruction and non‑mastectomy reconstruction CPT examples: 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367.
Obtain prior authorization before performing mastectomy or reconstruction; follow portal submission instructions or contact numbers for surgical authorizations.
Prior Authorization
Enteral services prior authorization
Enteral (in‑home nutritional) therapy and gastrostomy tube feeding require prior authorization. Authorization must be obtained before initiating or arranging in‑home enteral supplies or durable equipment billed to the plan.
Common enteral HCPCS codes that require prior authorization: B9002, B9004, B9006, B9998.
Prior authorization applies to in‑home enteral therapy delivered via gastrostomy tube as noted in the clinical/service entries.
Prior Authorization
FAI prior authorization
Femoroacetabular impingement (FAI) surgical management requires prior authorization. Confirm authorization for hip arthroscopy or related procedures prior to scheduling.
FAI arthroscopy CPT codes include: 29914, 29915, 29916.
Submit requests via the Prior Authorization and Notification tool on the provider portal or contact the plan for the applicable specialty line.
Prior Authorization
Gender dysphoria treatment prior authorization
Gender dysphoria-related surgical treatments and associated codes require prior authorization. Coverage is managed through authorization with linkage to the appropriate diagnosis codes; submit comprehensive clinical documentation with the request.
Example procedure codes and diagnosis links included in the source: CPT 55970, 55980, and numerous surgical codes listed in the policy tied to F64.x (F64.0, F64.8, F64.9) and related diagnosis codes.
Prior authorization must be obtained and should include the required diagnosis codes and supporting documentation for surgical and non‑surgical gender dysphoria treatments.
Prior Authorization
Home health care prior authorization
Home health care services billed to the plan require prior authorization for outpatient/home settings. Obtain authorization before initiating home health services to avoid claim denials.
Representative home health HCPCS/G‑codes: G0299, G0300, G0493, G0494, G0495, G0496, S9123, S9124, S9125, S9474.
Prior authorization applies when services are performed in the member's home or outpatient setting; follow portal submission instructions.
Prior Authorization
Hysterectomy prior authorization
Hysterectomy procedures require prior authorization. Submit requests prior to scheduling and include clinical indications and documentation supporting medical necessity.
Follow the Prior Authorization and Notification tool instructions or call the numbers provided on the member's ID card for surgical authorizations.
Prior Authorization
Prior authorization required for listed L-codes, select procedures
Many L‑codes (orthotics/prosthetics) and select procedures require prior authorization when they meet the payer's retail purchase or cumulative rental cost thresholds. Obtain authorization for high‑cost L‑codes or devices before procurement and fitting.
Prior authorization required for orthotics and prosthetics with retail purchase or cumulative rental cost greater than the plan threshold (example: more than $500 in some entries).
Representative L‑codes included in the policy: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0700, L0710, L0810–L0830, L0859, L1000–L1300 series, and numerous component/prosthetic L‑codes (L5726, L5728, L5780, L5790, L5795, L5811–L5858, L5930, L5950–L5999, L6000–L6010, L8687, L8688).
Obtain authorization via the portal and include cost information and clinical justification.
NoteDocument phrasing repeats 'For applied behavior analysis (ABA) therapy, submit via fax or Provider.'
PA referencesMastectomy entries include repeated references to obtaining prior authorization; specific portal guidance is given elsewhere in the document.
ContextCodes appear in multiple lines emphasizing prior authorization association with mastectomy-related services.
Injectable colony-stimulating factor drugs
Included drugsInjectable colony-stimulating factors listed include biosimilar Zarxio (Q5101) and multiple filgrastim/pegfilgrastim codes (J1449, J1442, Q5110, Q5125, Q5122, J2506, Q5120, Q5111, Q5108).
PA requirementThese colony-stimulating factor drugs require prior authorization when administered in an outpatient setting for a cancer diagnosis; some codes also require PA for non-oncology diagnoses.
SubmissionUse the Prior Authorization and Notification tool on UHCprovider.com; phone assistance available per cardiology/injectable instructions.
Bone-modifying agent
AgentDenosumab (Xgeva) — J0897
RequirementDenosumab is listed as a bone‑modifying agent that requires prior authorization when used as noted in the cancer supportive care section.
Related PA notesBone‑modifying agents appear in the injectable medications list subject to prior authorization and Review at Launch guidance for new drugs.
Inpatient video EEG
ServiceInpatient video electroencephalogram (EEG) — CPT codes include 95700, 95711–95718, 95720, 95722–95726.
PA requirementPrior authorization is required for inpatient video EEG; prior authorization is not required for outpatient hospital or ambulatory surgical center EEGs.
PurposeDescribed as continuous cerebral seizure monitoring performed in the inpatient setting.
Injectable chemotherapy drugs
ScopeInjectable chemotherapy drugs administered in an outpatient setting require prior authorization (HCPCS range J9000–J9999; leucovorin J0640).
Miscellaneous codesChemotherapy agents without assigned codes billed under miscellaneous HCPCS must use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.
SettingsIncludes intravenous and intrathecal outpatient chemotherapy for cancer diagnoses.
Continuous glucose monitor
Device codesContinuous glucose monitor supplies and device HCPCS listed include A4226, A4239, A9276, A9277, A9278, E0787 (and references to E2103/E2102).
PA requirementPrior authorization required when CGM is used with a Type 2 diabetes diagnosis.
NotesMultiple HCPCS entries appear with 'required with type 2' clarification in the CGM section.
PA thresholdPrior authorization required only for DME purchases or rentals when the cost exceeds referenced thresholds (cost of more than $500 referenced).
NotesSome entries distinguish prosthetics as not DME; rental and purchase entries are called out separately.
Experimental and investigational
DefinitionExperimental and investigational services — services and linked procedures that require prior authorization as listed (examples: 33477, 36514, 64722, 65765, 66180, A4638, A6000, A9274, E0231).
ApplicationMany CPT/HCPCS codes are enumerated under this category; prior authorization is required for items deemed experimental/investigational.
Provider actionSubmit requests via the Prior Authorization and Notification tool or contact the number on the member's ID for specifics.
Prior authorization requirement and submission methods (home health, outpatient, injectables)
RequirementPrior authorization is required for certain home health and outpatient services and for many injectable medications listed in the document.
Submission optionsSubmit prior authorization requests via the UnitedHealthcare Provider Portal Authorization and Notification tool (UHCprovider.com) or by phone (injectables phone: 888-397-8129 as noted).
ContextHome health codes listed include G0299, G0300, G0493–G0496, S9123, S9124, S9474; outpatient/home settings are specifically referenced as requiring PA in many entries.
Review at Launch
DefinitionReview at Launch — policy for New to Market Medications; predetermination is highly recommended for drugs on that list.
ContextReferenced alongside injectable medication lists and prior authorization instructions.
ActionCheck the Review at Launch Medication List for newly approved drugs to determine predetermination needs.
Prior notification
DefinitionPrior notification — specific prior notification required for certain drugs (example: Cimzia and Synagis should obtain prior notification through Optum Rx prior notifications at 800-310-6826).
ToolProvider Portal Prior Authorization and Notification tool (UHCprovider.com) — primary method for submitting prior authorization requests.
Access stepsSign in with One Healthcare ID at UHCprovider.com and select the Prior Authorization and Notification tab on your dashboard.
Alternate submissionPhone submission options are provided in the document for certain services; contact numbers vary by service section.
Ventricular assist devices (VAD)
DeviceVentricular assist devices (VAD) — defined as a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow.
PA/notification processVADs require prior authorization; call the notification number on the back of the member's health plan ID card and fax the provided form to Optum VAD Case Management at 855-282-8929.
ContextVAD entries emphasize direct notification and fax-based case management steps in addition to portal/phone workflows.