CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for UnitedHealthcare

List of services, CPT/HCPCS/ICD-10 codes, and instructions for submitting prior authorizations for participating UnitedHealthcare commercial plan providers; includes inpatient and outpatient services and notes state-specific rules.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or use 24/7 chat or the phone numbers listed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-05-01policy effective date

CSFs require PAcancer supportive care

Multipleservice categories

Portal / Chat / Phonesubmission methods

877-842-3210contact numbers

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 Conditions Requiring Prior Authorization or Notification

Bariatric surgery — Bariatric surgery and related obesity services

Covered when the following prior authorization conditions are met:

Bariatric surgery and specific obesity-related services require prior authorization.

Coverage may require treatment at a designated Center of Excellence.

Some benefit plans may not cover bariatric surgery or related services in certain situations; confirm member benefit coverage.

Injectable medications (oncology supportive care) — Cancer supportive care and certain injectable medications

Prior authorization required for specified injectable medications and supportive care agents when used as indicated:

Colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis require prior authorization.

Anti-emetics (ONE of)

Akynzeo (palonosetron/fosnetupitant) — J1454, J2469 requires prior authorization.
Cinvanti (aprepitant) — J0185 requires prior authorization.
Emend (fosaprepitant) — J1453, J1456 requires prior authorization.
Sustol (granisetron ER) — J1627 requires prior authorization.

Supportive care agents (ONE of)

Denosumab (Prolia/Xgeva) — J0897 requires prior authorization.
Erythropoiesis-stimulating agents (e.g., Epoetin alfa J0885) require prior authorization.
Colony-stimulating factor agents (e.g., Eflapegrastim J1449; Filgrastim J1442; Filgrastim biosimilar Q5110) require prior authorization.

Some codes listed for supportive care (J1442, J1447, J2506, Q51xx series) also require prior authorization when used for non-oncology diagnoses — check code-specific guidance.

Injectable chemotherapy drugs (J9000–J9999 and listed related J-codes) administered in an outpatient setting for a cancer diagnosis require prior authorization.

Breast reconstruction — Breast reconstruction (non-mastectomy) procedures and associated diagnosis codes

Breast reconstruction (non-mastectomy) procedures and selected diagnosis codes — prior authorization requirements:

Breast reconstruction (non-mastectomy) CPT/HCPCS procedures listed (e.g., 15771; 19300–19396; L8600) require prior authorization.

Diagnosis code exceptions (ONE of)

Notification/prior authorization is not required for a list of specific diagnosis codes (examples include C50.* ranges) when those DX codes apply; see enumerated ICD-10-CM codes in the breast reconstruction section.

Providers should reference the specific CPT/HCPCS and ICD-10-CM codes listed in the policy when submitting prior authorization requests for breast reconstruction services.

Orthopedic procedures — Arthroscopy and arthroplasty

Arthroscopy and arthroplasty procedures — prior authorization and site-of-service review rules:

Arthroscopy procedures (listed CPT codes such as 29805, 29820, 29824, 29826, 29830–29899 series) require prior authorization.

Prior authorization is required for arthroplasty CPT codes (examples enumerated in the document) — obtain prior authorization before scheduling.

Site-of-service review applies as part of prior authorization for listed arthroscopy and arthroplasty codes; exceptions for certain states/jurisdictions are noted in the policy.

Prior authorization criteria (partial — extract) — Selected medications, supportive care agents, specified procedures, and certain monitoring services require prior authorization as listed...

Selected prior authorization criteria (partial extract) for medications, monitoring and related services:

Anti-emetics listed (Akynzeo J1454/J2469; Cinvanti J0185; Emend J1453/J1456; Sustol J1627) require prior authorization when billed with their J-codes.

Supportive care agents including denosumab (J0897), erythropoiesis-stimulating agents (J0885), and colony-stimulating factors (J1449, J1442, Q5110) require prior authorization as specified.

Inpatient video EEG (codes 95700–95718) requires prior authorization; outpatient/ambulatory EEG (95720–95726) does not require prior authorization.

Injectable chemotherapy drugs administered in an outpatient setting (J9000–J9999 and specified related J-codes) require prior authorization for a cancer diagnosis.

Prior authorization and notification criteria (partial) — Items and services listed in these chunks are subject to prior authorization, advance notification, or are noted as not requiring prior a...

Prior authorization and notification expectations (partial):

Clinical trials (codes S9988, S9990, S9991) require prior authorization.

Cochlear and other auditory implants require prior authorization (see listed CPT/HCPCS codes).

Cosmetic and reconstructive procedures require prior authorization for all states; site-of-service review applies for listed codes except where noted.

Continuous glucose monitors require prior authorization when used with a type 2 diabetes diagnosis (A4226, A4238, A4239, etc.).

Operational prior authorization and notification rules (extract)

Operational rules that affect prior authorization and notification processing:

Prior authorization is required for cosmetic and reconstructive procedure codes listed; site-of-service will be reviewed and certain state exceptions apply (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands, Wisconsin).

DME codes listed require notification/prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000; prosthetics are not classified as DME and have separate thresholds.

Advance notification or prior authorization is required when members are referred outside the UnitedHealthcare network for ESRD dialysis services; providers should call 877-842-3210 for notification/prior authorization.

Prior authorization requirements (procedures, genetic testing, home health, hysterectomy, infertility)

Selected procedure categories and testing that require prior authorization or advance notification:

Genetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization; laboratories may need to notify UnitedHealthcare.

Home health non-nutritional services (T1000, T1002, T1003) require prior authorization when provided in outpatient settings, including the member's home.

Hysterectomy procedures: inpatient vaginal hysterectomies require prior authorization; abdominal and other inpatient/outpatient hysterectomies also require prior authorization as listed.

Infertility diagnostic and treatment services (numerous CPT/HCPCS codes listed) require prior authorization.

Screening colonoscopy coding and prior authorization context

Screening colonoscopy coding and when site-of-service applies:

Screening colonoscopy codes G0105 and G0121 are designated 'screening only' and site-of-service requirements may apply; prior authorization requests should be submitted via the Provider Portal or by calling 866-889-8054.

DX-dependent prior authorization (ONE of)

Some CPT/HCPCS procedure codes only require prior authorization when submitted with certain diagnosis codes — providers must reference the policy's DX code mappings.

For more details and the CPT codes that require prior authorization for GI endoscopy, providers should visit the Gastroenterology Endoscopy Advance Notification resource as noted in the policy.

Injectable medications prior authorization — Injectable medications and specialty therapies require prior authorization; some are limited by POS and require predetermination.

Injectable medications and specialty therapies — prior authorization and site-of-service considerations:

Certain enzyme replacement therapies and other specialty injectables are limited to POS 19 and 22 (inpatient/other specified POS) for prior authorization as noted (e.g., J3385 for Gaucher disease).

A broad range of injectable J-codes (hemophilia therapies, immune globulins, gene and rare-disease therapies) listed in the policy require prior authorization; providers should reference the specific J-codes in the document when submitting requests.

For oncology diagnoses, specific supportive care injectables and chemotherapy J-codes require prior authorization per the cancer supportive care section; for non-oncology uses some codes also require prior authorization — check code-specific notes.

Prior authorization and coverage nodes (excerpt)

Service-level prior authorization requirements and coverage qualifications (excerpt):

MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid (CPT 0071T, 0072T) requires prior authorization; coverage is limited to certain benefit plans and requires contracted facilities, documented provider/facility experience, and member written consent acknowledging limited published evidence.

Non-emergency air transport and nonurgent ambulance codes listed require prior authorization.

Orthognathic surgery CPT codes listed require prior authorization.

Orthotics require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000.

Potentially unproven or experimental services listed require prior authorization.

Prosthetics prior authorization criteria

Prosthetics prior authorization threshold (partial):

Prior authorization is required for prosthetic codes listed when the retail purchase price or cumulative rental cost is greater than $1,000.

Radiation therapy prior authorization criteria

Radiation therapy prior authorization conditions (partial):

Prior authorization is required for listed radiation therapy procedures (e.g., IGRT 77014, 77387; IMRT 77385/77386) and associated codes.

Standard radiation therapy codes (e.g., 77401, 77402, 77407, 77412) require prior authorization only when billed with diagnosis codes in specified cancer diagnosis ranges (e.g., C34.*, C50.*, C61, C79.51–C79.52).

Procedure-specific prior authorization — Specific procedures requiring prior authorization:

Specific procedures that require prior authorization (examples):

Prostate procedures (ONE of)

Prostate procedure CPTs listed (e.g., 52441, 52442, 53850, 55874) require prior authorization.

Rhinoplasty and nasal procedures (ONE of)

Rhinoplasty CPTs (30410, 30420, 30430) require prior authorization for participating physicians; submit requests via the Provider Portal or call 866-889-8054.
Sinuplasty CPTs (31295–31298) require prior authorization when performed in outpatient hospital/ASC settings per site-of-service rules.

Providers must follow the prior authorization submission instructions (UnitedHealthcare Provider Portal or phone) when requesting authorization for these procedures.

Partial SOS and procedure prior authorization criteria

Site-of-service and procedure-specific prior authorization rules (partial):

Prior authorization is required when procedures are requested in an outpatient hospital setting or ambulatory surgical center (ASC); prior authorization is not required when performed in an office-based program or at participating providers in certain jurisdictions (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands, Wisconsin).

Sinuplasty (CPTs 31295–31298) requires prior authorization.

Submit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 866-889-8054 as noted in the policy.

Prior authorization and site-of-service criteria (codes listed)

Prior authorization and site-of-service expectations for numerous procedural codes:

Prior authorization is required for listed CPT/HCPCS codes when performed at specified sites of service (commonly outpatient hospital) as noted in the policy.

The document provides extensive code groupings by body system; providers should reference the listed CPT/HCPCS codes when obtaining prior authorization.

Site-of-service (SOS) is repeatedly specified as 'outpatient hospital' for many codes; confirm SOS when submitting authorization requests.

Prior authorization requirements (excerpt)

Prior authorization requirements (excerpt) — selected services and codes:

Surgical sleep apnea procedures (e.g., maxillomandibular advancement; CPT examples 21685, 41599, 42145) require prior authorization for all states.

Laboratory-assisted sleep studies (polysomnography; e.g., 95805, 95807, 95808, 95810, 95811) require prior authorization (home sleep studies excluded).

Spinal cord stimulator implantation CPTs and related HCPCS L-codes (e.g., 63650, 63655, 63685 and L-series device codes) require prior authorization for all states; site-of-service review may apply.

Spinal surgery codes (extensive listing including 63000–63308 ranges and many related codes) require prior authorization for all states; site-of-service may be reviewed.

Prior authorization coverage criteria (enumerated services)

Prior authorization coverage criteria and notable exceptions (enumerated services):

Prior authorization is required for the enumerated CPT/HCPCS codes across all states, with site-of-service review applied as noted; certain state exceptions are listed in the policy.

Code-specific conditions (ONE of)

Certain combinations of procedure codes and incontinence diagnosis codes are exempt from prior authorization as indicated in the policy (noted with an asterisk).
Code 38232 requires prior authorization only for oncology diagnoses.

Therapeutic radiopharmaceuticals require prior authorization and should be submitted via the Provider Portal with the specified submission instructions.

Transplant and transplant-related pre-treatment/evaluation services require prior authorization; certain cellular and gene therapies have specific call/notification instructions as noted.

CPT, HCPCS, ICD-10 and Other Codes Called Out

Arthroplasty codesCPTCovered

23470	Arthroplasty-related CPT/HCPCS code listed
23472	Arthroplasty-related CPT/HCPCS code listed
23473	Arthroplasty-related CPT/HCPCS code listed
23474	Arthroplasty-related CPT/HCPCS code listed

Injectable medication codes requiring prior authorizationHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J2469	Akynzeo (additional HCPCS listed)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1456	Emend (additional HCPCS listed)
J1627	Sustol (granisetron extended release)
J0897	Denosumab (Prolia/Xgeva)
J0885	Epoetin alfa
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)

1–10 of 11

1/2

Anti-emeticsHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J2469	Akynzeo (additional HCPCS listed)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1456	Emend (additional HCPCS listed)
J1627	Sustol (granisetron extended release)

Bone-modifying agents, ESAs, and CSFsHCPCSCovered

J0897	Denosumab (Prolia, Xgeva)
J0885	Epoetin alfa (ESA)
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)

Injectable chemotherapy and related drugsHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs (range)
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Leuprolide acetate
J1952	Leuprolide

Cartilage implants and related surgical codesmixedCovered

27412	Cartilage implant procedure
27415	Cartilage implant procedure
27416	Cartilage implant procedure
29866	Arthroscopy procedure
29867	Arthroscopy procedure
29868	Arthroscopy procedure
J7330	Prosthetic/implant HCPCS
S2112	Supply/service HCPCS

Selected procedural and device codes (examples)mixedCovered

27412	Cartilage implant - CPT
27415	Cartilage implant - CPT
27416	Cartilage implant - CPT
29866	Arthroscopy-related code listed
29867	Arthroscopy-related code listed
29868	Arthroscopy-related code listed
J7330	Implantable device HCPCS listed

Continuous glucose monitor codesHCPCSCovered

A4226	CGM receiver/transmitter - HCPCS
A4238	CGM supplies - HCPCS
A4239	CGM supplies - HCPCS

Reconstructive / cosmetic procedure CPT codes (partial list)CPTCovered

15879	Listed among reconstructive/cosmetic procedure codes in the section
17999	Listed among reconstructive/cosmetic procedure codes in the section
21137	Reconstructive procedure code listed
21138	Reconstructive procedure code listed

Durable medical equipment / K- and E- codes (partial list)HCPCSCovered

E0328	DME code listed
K0005	DME/prosthetic-related code listed

Colonoscopy screening codesCPT | HCPCSCovered

G0105	Colorectal cancer screening; flexible sigmoidoscopy
G0121	Colorectal cancer screening; colonoscopy on individual at high risk

Genetic and molecular testing (example codes)CPTCovered

81162	BRCA1/BRCA2 analysis
81400	Molecular pathology procedure level I
81479	Unlisted molecular pathology procedure

Selected S-codes requiring prior authorization contextHCPCS

S4011
S4013
S4014
S4015
S4016
S4022
S4023
S4025
S4026
S4028

1–10 of 14

1/2

Sample J-codes listed under injectable medications/prior authorizationHCPCS

J0256	injectable medication (specific product not named here)
J0257
J1437
J1439
J2182
J2356
J2786
J1307
J0223
J1299

1–10 of 13

1/2

Additional J-codes and categoriesHCPCS

J3385	enzyme deficiency (Gaucher disease) - POS 19 and 22 only
J0885	erythropoiesis stimulating agents
J1411
J1412
J1413
J1414
J3398
J3399
J3401

Immune globulin and related codesmixed

90283	immune globulin administration
90284
J1459
J1551
J1555
J1556
J1557
J1558

MRgFUS codesCPT | HCPCS | mixedCovered

0071T	MRgFUS procedure code
0072T	MRgFUS procedure code

Non-emergency air transportCPT | HCPCS | mixedCovered

A0430	Air ambulance, fixed wing or rotary
A0431	Non-emergency air transport
A0435	Non-emergency air transport
A0436	Non-emergency air transport
S9960	Nonurgent ambulance transportation by air
S9961	Nonurgent ambulance transportation by air

Orthotics (selected codes)HCPCSCovered

L0220	Orthotic code (example listed)
L3900	Orthotic code (example listed)

Facet treatment codes (AZ-specific prior auth rules)CPTCovered

64490	Facet joint injection code (example)
64491	Facet joint injection code (example)

Potentially unproven services (selected)CPTNot Covered

26340	Potentially unproven service code
33361	Potentially unproven service code

Pregnancy notification ICD-10-CM codes (examples shown)ICD-10

O09.00	Supervision of pregnancy with history of fertility problems, unspecified (example mapping present)
O09.01	Supervision of pregnancy with assisted reproduction (example mapping present)
O09.02	Supervision of pregnancy with other specified conditions (example mapping present)

Prosthetics HCPCS/L-code groupHCPCSCovered

L5010	Prosthetic code example (listed among many L-codes requiring prior auth threshold)
L5050	Prosthetic code example
L5100	Prosthetic code example

Radiation therapy CPT/HCPCS codesCPTCovered

77014	IGRT imaging code listed for prior auth
77385	IMRT planning/therapy code listed for prior auth
G0339	Radiation therapy related code listed

Selected digestive/colonoscopy CPTs (partial)CPT

57421	Colonoscopy related CPT listed in excerpt
57425	Colonoscopy related CPT listed in excerpt
57452	Colonoscopy related CPT listed in excerpt
57454	Colonoscopy related CPT listed in excerpt
57456	Colonoscopy related CPT listed in excerpt
57461	Colonoscopy related CPT listed in excerpt

ENT / nasal procedure CPTs (partial)CPT

31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty
31298	Sinuplasty
30410	Rhinoplasty code listed

Foot surgeryCPT

28295

Foot surgery code listed multiple times

Male genital systemCPT

54001	Male genital system surgery codes (example)
54600	Male genital system surgery codes (example)

Musculoskeletal / chest wallCPT

24000	Musculoskeletal system procedure examples
24130	Breast/chest wall procedure examples

Selected spinal cord stimulator implantation codesCPTCovered

63650	Percutaneous implantation of neurostimulator electrode array; spinal cord
63655	Laminectomy for implantation

Spinal surgery codesCPTCovered

63661	Insertion or replacement of spinal neurostimulator pulse generator or receiver
63030	Laminectomy, facetectomy and foraminotomy (example spinal surgery codes listed)

Spinal surgery / spine codesCPTCovered

63265-63295, 63300-63308, 0098T	Spinal surgery related CPT codes (listed across chunks)
22513-22514	Spine-related CPT codes

Neurostimulators and therapeutic radiopharmaceuticalsmixedCovered

E0748, E0749, 43647-43882, 61863-61886, 64555-64595, 64561, 64581	Neurostimulator and related HCPCS/CPT codes for implantation of stimulators (not related to spine)
A9513, A9607	Therapeutic radiopharmaceuticals (examples listed)

Vein procedures and VAD codesCPTCovered

36470-36479, 37243, 37700, 37718, 37722, 37780	Vein procedure CPT codes (removal/ablation of saphenous veins)
33927-33929, 33975-33983	Ventricular assist device related CPT codes

Transplant and transplant-related codesmixedCovered

38240-38242, S2150, 99205, 33930-33945, 44135-44136, 50300-50370, 47135-47147, 32850-32855, 48551-48554, 50325, S2054, S2140, S2142, S2152

Transplant and transplant-related service CPT/HCPCS codes; pre-treatment/evaluation codes including 99205 and multiple organ transplant procedure codes

Cancer outpatient requirement — prior authorization

How Providers Should Submit Requests and Operational Steps

Prior Authorization

Exemption — outpatient EEG

Prior authorization is not required for outpatient hospital or ambulatory surgery center EEG (CPT codes 95720, 95722, 95724, 95726). However, prior authorization is required for inpatient video EEG/seizure monitoring (CPT codes 95700–95718).

Outpatient EEG codes exempt from prior authorization: 95720, 95722, 95724, 95726
Inpatient video EEG/seizure monitoring requires prior authorization: 95700–95718

Prior Authorization

Congenital heart disease services - advance notification

Congenital heart disease-related services, including pretreatment evaluation, require advance notification. To notify, call 888-936-7246 or use the notification number on the back of the member's health plan ID card.

Advance notification required for congenital heart disease services including pretreatment evaluation
Call 888-936-7246 or the notification number on the member's ID card to submit advance notification

Definitions and Thresholds

Prior authorization — definition and submission

DefinitionPrior authorization is a required review process for certain services and codes before they are provided; emergency and urgent care are exempt.

Submission methodsRequests may be submitted online via the Prior Authorization and Notification tool on UHCprovider.com or via 24/7 chat as outlined in the Provider Portal instructions.

UpdatesThis list changes periodically; providers should check UnitedHealthcare Network News or the Provider Portal for the most current information.

Center of Excellence requirement (bariatric)

RequirementBariatric surgery and specific obesity-related services require prior authorization and coverage may require treatment at a designated Center of Excellence.

Codes (examples)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or use 24/7 chat or the phone numbers listed.

SourceLink

On This Page

Providers should check Review at Launch and use the Provider Portal or phone contacts for products billed with unclassified/temporary codes (C9399, J3490, J3590) as notification/prior authorization applies only for specified products.

Ventricular assist devices (VADs) require advance notification via the number on the member's ID card and coordination with the Optum VAD Case Management Team where specified.

RequirementPrior authorization required for colony-stimulating factor drugs and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis.

Example codesJ1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125 (these also require prior authorization for non‑oncology diagnoses).

Submission noteSubmit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or as directed for specialty pharmacy items.

DME cumulative rental/purchase cost threshold

ThresholdDME items listed require notification/prior authorization when retail purchase or cumulative rental cost is more than $1,000.

ScopeApplies only to DME codes enumerated in the DME list; prosthetics are not classified as DME (see prosthetics threshold).

Example codesE0328, E0329, E0466, E0471, E0483, E0745 (among others listed in the DME section).

Site of service restriction

POS restrictionCertain enzyme replacement therapies and multiple sclerosis therapies require services billed at POS 19 and 22 only (inpatient/other specified POS) for prior authorization.

Example J-codesJ0180, J0217, J0218 and J2323 (listed as POS 19 and 22 only for enzyme replacement and some MS therapies).

ActionConfirm place-of-service on submission; requests submitted for other POS may be denied or returned for correction.

Orthotics purchase/rental cost threshold

ThresholdPrior authorization required for orthotics codes listed when retail purchase or cumulative rental cost exceeds $1,000.

ExamplesL0220, L0482, L0484, L0486, L0636, L0638, L1640, L1680 (selected orthotics codes listed).

Scope noteRequirement applies only to orthotics codes that are included in the orthotics list with the cost threshold; other orthotics may not require prior authorization.

Prosthetic prior authorization threshold

ThresholdPrior authorization required for prosthetic codes listed when retail purchase or cumulative rental cost is more than $1,000.

ExamplesL5010, L5050, L5100, L5105, L5150 (sample L‑codes listed among many subject to the threshold).

Scope noteApplies only to prosthetic codes enumerated in the prosthetics section; providers should confirm code-specific prior authorization requirements.

Code 38232 prior authorization condition

ConditionCPT code 38232 requires prior authorization only when billed with an oncology diagnosis.

Related codesQ2056, Q2057 referenced in the same section where 38232 condition is noted.

Submission instructionWhen 38232 is submitted for oncology DX, include supporting oncology diagnosis codes to justify prior authorization request.

Prior Authorization

Endoscopy, GI, sinus and related procedures — prior authorization/advance notification

Gastroenterology endoscopy and related procedures (including EGD, colonoscopy, capsule endoscopy and functional endoscopic sinus procedures) require prior authorization or advance notification as indicated. Screening colonoscopies have site-of-service review and may require prior authorization depending on place of service and codes.

Advance notification encouraged for GI endoscopy (EGD, colonoscopy, capsule endoscopy)
Functional endoscopic sinus procedures (e.g., 31240, 31253–31259, 31267, 31276, 31287–31288) require prior authorization
Screening colonoscopy procedures may be subject to site-of-service review; see Colonoscopy screening section for codes and submission details

Prior Authorization

Colonoscopy screening prior authorization and submission instructions

Screening colonoscopies (including HCPCS/G-codes G0105, G0121 and listed CPT colonoscopy screening codes) may be subject to site-of-service review. Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054.

Screening colonoscopy G-codes: G0105, G0121
Use the Prior Authorization and Notification tool on UHCprovider.com (Sign In with One Healthcare ID)
Or call 866-889-8054 for authorization assistance

Prior Authorization

Home health care (non-nutritional) prior authorization

Home health care services (non-nutritional) require prior authorization. Affected HCPCS/CPT codes include T1000, T1002, T1003 and other home health service codes; check member benefits and submit prior authorization via the Provider Portal.

Home health care (non-nutritional) codes: T1000, T1002, T1003
Submit requests online using the Prior Authorization and Notification tool on UHCprovider.com

Prior Authorization

Non-emergency air transport / Nonurgent ambulance

Non-emergency air transport / nonurgent ambulance services require prior authorization. Affected HCPCS codes include A0430, A0431, A0435, A0436 and related S-codes (S9960, S9961).

Non-emergency air transport / Nonurgent ambulance codes: A0430, A0431, A0435, A0436, S9960, S9961
Prior authorization required before scheduling nonurgent ambulance air transport

Prior Authorization

Orthotics (cost threshold prior auth)

Orthotics require prior authorization only when the retail purchase or cumulative rental cost exceeds $1,000. The listed HCPCS orthotics codes are subject to this cost-threshold prior authorization requirement.

Cost-threshold prior authorization applies when retail purchase or cumulative rental > $1,000
Examples of orthotics codes subject to prior authorization: L0220, L0482, L0484, L0486, L0636, L0638, L1640, L1680, L1685, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034, L2036, L2037, L2038, L2330, L3251, L3253, L3485, L3766, L3900, L3901, L3904, L3961, L3971, L3975, L3976, L3977

Prior Authorization

Prescription drug / J-code prior authorization notes

Prescription drugs, including many J‑code injectable medications, require prior authorization. Providers may submit specialty and medication prior authorization requests via the Provider Portal Specialty Pharmacy Transactions tile, or contact the phone numbers listed for specific drug classes. For drugs requiring pharmacy prior authorization call the pharmacy number on the plan or submit via the Portal; specialty medication fax for some requests: 877-342-4596.

Injectable J‑codes often requiring prior authorization: J9000–J9999 and specific J‑codes (see drug-specific sections)
Submit medication prior authorizations via the UnitedHealthcare Provider Portal Specialty Pharmacy Transactions tile
For pharmacy prior authorization questions call the plan pharmacy number or 800‑711‑4555 (per plan materials) and fax specialty medication requests to 877‑342‑4596 when instructed

Prior Authorization

Out-of-network services prior authorization

Out-of-network services require prior authorization when a network physician or other provider recommends referral to a non‑contracted hospital, physician or facility. Such referrals may increase member out‑of‑pocket costs and may be subject to network agreement restrictions.

Prior authorization required when directing members to out-of-network providers per contract terms
Use the Provider Portal or contact the number on the member's ID card for authorization and to determine member benefits

Prior Authorization

Prostate procedures prior authorization

Prostate procedures (including codes such as 52441, 52442, 53850, 55874) require prior authorization. Confirm codes and clinical indications when submitting requests.

Examples of prostate procedure codes requiring prior authorization: 52441, 52442, 53850, 55874
Submit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com

Prior Authorization

Rhinoplasty prior authorization and submission instructions

Rhinoplasty and related nasal functional procedures require prior authorization. For participating physicians, submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

Rhinoplasty procedure codes: 30410, 30420, 30430 (and related functional nasal codes 30435, 30450, 30460, 30462)
Submit prior authorization via UHCprovider.com Prior Authorization and Notification tool or call 866-889-8054

Note

Prior authorization submission pathway

Submit prior authorization and notification requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with One Healthcare ID. Where available, phone numbers cited in each clinical section (for example 866-889-8054 or specialty drug lines) may be used as alternate submission routes.

Primary submission pathway: Prior Authorization and Notification tool on UHCprovider.com (Sign In with One Healthcare ID)
Alternate phone submission numbers are provided in specific clinical sections (e.g., 866‑889‑8054)

Prior Authorization

Prior authorization for listed outpatient hospital procedures

Many outpatient hospital procedures listed in this document require prior authorization; site-of-service review may apply for certain codes. Confirm the specific CPT/HCPCS codes in the applicable clinical sections and submit authorization requests via the Provider Portal.

Prior authorization required for listed outpatient hospital procedures; site-of-service review applies for specified codes
Confirm CPT/HCPCS codes in the clinical sections before submitting authorization requests online

Prior Authorization

Prior authorization — hemic and lymphatic system procedures

Hemic and lymphatic system procedures (e.g., hematopoietic cell collection and transfusion codes such as 38221, 38222, 38500–38525, 38740, 38760) require prior authorization. Note: code 38232 may require prior authorization only for an oncology diagnosis—verify per clinical guidance.

Examples of hemic and lymphatic procedure codes requiring prior authorization include: 38221, 38222, 38500, 38505, 38510, 38520, 38525, 38740, 38760
Code 38232: prior authorization required only for an oncology diagnosis (verify case-specific requirements)

Prior Authorization

VAD notification process

Ventricular assist devices (VAD) require notification and prior authorization. Call the notification number on the member's ID card first, then fax the form provided by the nurse to the Optum VAD Case Management Team as directed.

VAD prior authorization required; example CPT/HCPCS codes include 33927, 33928, 33929, 33975–33983
Notification pathway: call the notification number on the member's ID card, then fax the completed form to the Optum VAD Case Management Team per instructions provided by the nurse

43644, 43645, 43659, 43770–43775, 43842–43847 (selected bariatric procedure codes listed).

Plan limitationsSome benefit plans may not cover bariatric surgery in certain situations; verify member's benefit plan and Center of Excellence requirements.

Prior authorization (general)

LabelPrior authorization (general).

Portal instructionSubmit prior authorization requests using the UnitedHealthcare Provider Portal; phone alternatives provided for certain lines (e.g., 888‑397‑8129, 866‑889‑8054).

PredeterminationPredetermination is recommended for certain specialty drugs and Review at Launch items.

Clinical trials — definition

DefinitionClinical trials are rigorously controlled studies of a new drug, medical device, or other intervention; prior authorization is required for clinical trial-related services.

Example codesS9988, S9990, S9991 (clinical trial-related HCPCS codes listed).

ActionInclude clinical trial identifiers and documentation when submitting prior authorization for trial-related services.

Durable Medical Equipment (DME) — definition

DefinitionDurable Medical Equipment (DME) items listed require notification/prior authorization when retail purchase or cumulative rental cost exceeds $1,000.

ExamplesE0328, E0466, E0745 and many E-/K- codes listed in the DME section.

ExclusionProsthetics are not considered DME for this threshold—see prosthetics section.

ESRD dialysis notification — contact/process

Notification contactFor ESRD dialysis notification/prior authorization call 877-842-3210.

ScopeAdvance notification or prior authorization is required when members are referred outside the UnitedHealthcare network for ESRD dialysis services.

ActionCall the number provided prior to arranging out-of-network ESRD dialysis services to ensure authorization/notification processing.

Provider Portal and phone number for submissions

Provider PortalUse the Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID) to submit prior authorization and predetermination requests.

Phone alternativesPhone numbers listed in the document include 888-397-8129 and 866-889-8054 for certain lines; specialty pharmacy phone references also appear (888‑397‑8129).

Chat optionProviders can connect via 24/7 chat through the Contact Us page on the Provider Portal as an alternative submission route.

Genetic and molecular testing (BRCA) prior authorization

RequirementGenetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization.

Example codes81162 (BRCA), 81400, 81479 and numerous proprietary U-codes listed for molecular testing.

Laboratory notificationLaboratories may need to notify UnitedHealthcare; providers should follow Portal submission instructions for these tests.

Predetermination — submission via Provider Portal

DefinitionPredetermination refers to submitting a predetermination request or prior authorization via UHCProvider.com (Provider Portal / Specialty Pharmacy Transactions tile).

How to submitLog in to UHCprovider.com, select the Provider Portal and use the Prior Authorization and Notification tool or the Specialty Pharmacy Transactions tile for predetermination submissions.

Phone backupSome specialty pharmacy lines provide phone numbers (e.g., 888‑397‑8129) for assistance; Portal submission is preferred.

C9399, J3490, J3590 — handling for unclassified/temporary codes and new drugs

Handling ruleUnclassified/temporary codes C9399, J3490, J3590 require notification/prior authorization only for specific products (e.g., Nulibry™, Rivfloza™, Revcovi™).

RecommendationCheck the 'Review at Launch' New to Market Medications policy; predetermination is highly recommended for drugs on that list.

ActionWhen submitting for unclassified/temporary codes, include product-specific identifiers to confirm whether prior authorization is required.

MRgFUS — definition and coverage

DefinitionMRgFUS (MR-guided focused ultrasound) is a procedure used to treat uterine fibroid; prior authorization is required and coverage is limited to certain benefit plans with specific facility/provider requirements.

Codes0071T, 0072T (MRgFUS procedure codes listed).

ConditionsCovered only when member consent acknowledges limited published evidence, facility contracted with UnitedHealthcare, and provider/facility demonstrate required experience.

Potentially unproven services — definition

DefinitionPotentially unproven services are experimental/investigational services or linked services determined to have insufficient clinical evidence in peer‑reviewed literature; prior authorization is required for listed codes.

ExamplesCPT codes 26340, 33361, 33362, 33363, 33364, 33365, 33366, 33369, 33477, 36514, 64722 are listed as potentially unproven and require prior authorization.

Decision basisDeterminations are based on lack of sufficient evidence from well‑conducted randomized controlled trials or cohort studies.

Prior authorization required — general note

General notePrior authorization is required for listed services and codes before they are provided; emergency and urgent care are excluded.

Submission pathwaySubmit requests online via the Prior Authorization and Notification tool on UHCprovider.com; phone backup is 866‑889‑8054 as noted in the document.

Site-of-service reviewSite-of-service will be reviewed as part of prior authorization for many codes; exceptions and state-specific rules are noted in the policy.

Voluntary notification — pregnancy

DefinitionVoluntary notification: Providers should notify the payer upon confirmation of pregnancy for specified ICD‑10‑CM codes; notification does not determine coverage and should be submitted once per pregnancy.

ExamplesICD‑10 mappings and example codes shown (O09.* mappings to other O‑codes and O21.*, O24.* series).

ActionSubmit voluntary notification via the Provider Portal or as directed to enroll the member in case/disease management if applicable.

Site of service (SOS) — definition

DefinitionSite of service (SOS) indicates where a procedure is performed (office-based, outpatient hospital, ASC) and determines whether prior authorization is required.

Rule exampleSome procedures require prior authorization only when performed in an outpatient hospital or ASC; they may be exempt if performed in an office-based program or at participating providers in specified jurisdictions.

ExceptionsCertain states/jurisdictions (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin) are listed as exceptions for SOS rules.

Prior authorization submission methods — Provider Portal

Portal submissionPrior Authorization and Notification tool on UnitedHealthcare Provider Portal is the primary method for submitting prior authorization requests.

Phone backupPhone number 866-889-8054 is provided as an alternative for prior authorization requests where applicable.

Specialty pharmacy tileUse the Specialty Pharmacy Transactions tile on the Provider Portal for predetermination/prior authorization of specialty drugs.

Site of service (SOS) — outpatient hospital

DefinitionSite of service (SOS) — outpatient hospital (SOS designation used repeatedly to indicate where prior authorization applies).

ImplicationWhen SOS is specified as outpatient hospital, prior authorization may be required for that setting; perform validation on claims/submissions.

Provider actionConfirm SOS on the prior authorization request and specify clinical rationale for outpatient hospital setting when requested.

Site of service (SOS) — site‑of‑service review

DefinitionSite‑of‑service (SOS) review: the payer reviews the place of service as part of the prior authorization process and may require prior authorization based on SOS.

State exceptionsSOS review excludes certain jurisdictions (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin) for many listed codes.

Provider instructionIndicate intended place of service on authorizations; the reviewer may request additional documentation for SOS exceptions.

Spinal cord stimulator prior authorization

RequirementPrior authorization required for spinal cord stimulator implantation codes and related device HCPCS L‑codes.

ExamplesCPT codes: 63650, 63655, 63685, 63688; HCPCS L‑codes: L8679, L8685, L8680, L8686 (listed in the stimulator section).

Pharmacy contactFor associated medications that require prior authorization, contact the pharmacy/specialty number provided in the document.

Ventricular assist devices (VAD) — definition and process

DefinitionVentricular assist devices (VAD) are mechanical pumps that take over the function of a damaged ventricle; prior authorization/notification is required.

ProcessCall the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management Team as instructed.

Example codesCPT codes: 33927–33929, 33975–33983 listed for VAD procedures requiring prior authorization/notification.

Stimulators — not related to spine

DefinitionStimulators (not related to spine) refer to implantation of devices that send electrical impulses (neurostimulators); prior authorization is required for listed codes.

ExamplesCPT codes: 43647–43648, 61863–61886, 64555–64595 and HCPCS examples E0748/E0749 for neurostimulators are included in the stimulator sections.

SOS noteSite‑of‑service will be reviewed as part of prior authorization for stimulators; state exceptions may apply.

Therapeutic radiopharmaceuticals — require prior authorization

RequirementTherapeutic radiopharmaceuticals require prior authorization and have special submission instructions via the Provider Portal.

Example HCPCSA9513, A9607 listed as therapeutic radiopharmaceutical examples that require prior authorization.

Submission instructionTo submit a therapeutic radiopharmaceutical prior authorization (or predetermination for nonparticipating providers), log in to the Provider Portal at UHCprovider.com.