CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

List of services, procedures and drugs that require prior authorization for participating UnitedHealthcare Community Plan of Pennsylvania providers and instructions on how to submit requests; applies to inpatient and outpatient services and participating/out-of-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 800-366-7304, or by fax at 800-600-9007.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul. 1, 2025effective date shown

800-366-7304prior auth phone

UHCprovider.comprior auth portal

$500DME prior auth threshold

PA requiredEnteral services

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.

Prior Authorization — Coverage Criteria

Prior authorization required items

Services and drugs listed require prior authorization as noted.

Colony-stimulating factor drugs and bone-modifying agent administered in an outpatient setting for a cancer diagnosis require prior authorization.

Examples

Eflapegrastim (Rolvedon) — J1449
Filgrastim (Neupogen) — J1442
Filgrastim biosimilars — Q5101, Q5110, Q5125, Q5122, Q5120, Q5111, Q5108
Pegfilgrastim (Neulasta) — J2506
Denosumab (Xgeva) — J0897 (bone-modifying agent)

Certain listed colony-stimulating factor codes (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) also require prior authorization when used for non-oncology diagnoses.

Partial coverage criteria from excerpt

Coverage/authorization stance for specific services in this excerpt (partial).

Cerebral seizure monitoring (inpatient) — prior authorization required (codes: 95700, 95711, 95712, 95713).

EEG in outpatient hospital or ambulatory surgical center (codes: 95720, 95722, 95724, 95726) — prior authorization not required for outpatient setting.

Injectable chemotherapy drugs administered in an outpatient setting (including J9000-J9999, Q-codes, unassigned/miscellaneous HCPCS, and specified codes J0640, J0641, J0642, J1950) — prior authorization required; submit via UHCprovider.com or call 888-397-8129.

Continuous glucose monitor for Type 2 Diabetes (codes: A4226, A9277, E2103, A4238, A9278, A4239, E0787, A9276, E2102) — prior authorization required; some products not reimbursable on medical benefit and should be submitted to OptumRx.

Cochlear implants and related auditory implant codes (e.g., 69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692) — prior authorization required.

Coverage notes and authorization triggers (partial)

Procedures, DME, and enteral services coverage-related rules and authorization triggers as listed below (partial extract).

DME prior authorization rule: Prior authorization is required only for DME codes with a retail purchase or cumulative rental cost of more than $500; prosthetics are not considered DME.

Enteral services (examples: B4034, B4035, B4036, B4100) — prior authorization required.

Reconstructive and cosmetic procedure codes — multiple CPT/HCPCS entries listed with prior authorization guidance; some entries include additional information or exceptions.

Prior authorization requirements (partial)

Services and codes in this excerpt that are subject to prior authorization:

Enteral services and in-home nutritional services (codes B4034, B4035, B4036, B4100, B4102, B4103, B4104) — prior authorization required.

Experimental and investigational services (examples: 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000) — prior authorization required.

Genetic and molecular testing performed in outpatient setting (examples: 81163, 81164, 81228, 81229, 81277, 81400–81405, 81523, 81541–81542, 81552, S3854, S3865, S3870) — prior authorization required.

Home health services (examples: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474) — prior authorization required only in outpatient settings, including member's home.

Hospice (code T2045) — prior authorization required.

Authorization and coding listing

Listing of services/drugs and prior authorization requirements

Home health services require prior authorization in outpatient/home settings (see G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124, S9474).

Hospice services require prior authorization (T2045).

Hysterectomy procedures listed require prior authorization (multiple CPT codes enumerated in the hysterectomy section).

Human milk bank services — prior authorization required.

Numerous injectable medications (J-/Q- codes such as J3262, J0801, J0791, J7192, J7207, J1426 and many others across chunks 75–126) require prior authorization.

Prior authorization and admission notification requirements

Prior authorization and notification expectations for medications and inpatient admissions

Submit prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call 888-397-8129.

Pre-determination is highly recommended for drugs on the Review at Launch Medication List.

Prior authorization and notification of admission date are required for facilities providing post-acute inpatient services, including acute care hospitals, acute inpatient rehabilitation, and critical access hospitals.

Administrative coverage criteria (partial)

Coverage-related operational criteria from this document segment (partial):

Prior authorization is required for the listed J/Q drug codes; submit requests via UHCprovider.com or call 888-397-8129.

Notification and/or prior authorization required for inpatient admissions and for facilities providing post-acute inpatient services (acute care hospitals, acute inpatient rehabilitation, critical access hospitals); pre-determination recommended for Review at Launch drugs.

Orthotics and prosthetics prior authorization rule: prior authorization is required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost exceeding $500.

Orthotics & Prosthetics authorization notes

Coverage-related notes for orthotics and prosthetics L-codes in this section.

Prior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 (examples of L-codes listed: L0632, L0634, L0636, L0637, L0640, L2038, L2060, L2106, L2108, etc.).

This section enumerates HCPCS L-codes for orthotics and prosthetics and indicates where to find CPT/HCPCS codes and prior authorization procedures.

Prior authorization requirements (excerpt)

Items and services in this excerpt that have explicit coverage-related notes:

Private duty nursing (T1000, T1002, T1003) — prior authorization required.

Pediatric day services (PDHC) (T1024) — prior authorization required.

Prostate procedures (codes include 37243, 52441, 52442, 53850) — prior authorization required.

Proton beam therapy (codes 77520, 77522, 77523, 77525) — prior authorization required.

Radiology — advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) require notification/prior authorization; to request prior authorization call 866-889-8054 or submit via UHCprovider.com.

Prior authorization statements

Sections explicitly stating prior authorization requirement

Sleep apnea procedures and surgeries — prior authorization required.

Spinal surgery procedures — prior authorization required.

Stimulators (including bone growth stimulators and neurostimulators) — prior authorization required; implantation and device codes listed (e.g., E0747, E0748, E0749, E0760, L8680–L8688, etc.).

Transplants — prior authorization required.

Prior authorization coverage criteria (partial list)

Prior authorization required for listed services and codes:

Stimulators (implants and neurostimulators) — prior authorization required; see stimulator HCPCS/CPT codes listed (examples: E0747, E0748, E0749, E0760, L8680–L8688).

Transplants and CAR T-cell therapy — prior authorization required; for transplant and CAR T-cell therapy services call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card.

Vein procedures (removal/ablation of saphenous trunks and named branches) — prior authorization required (examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780).

Ventricular assist devices (VAD) — prior authorization required; call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case team (codes include 33927–33929, 33975–33983, Q0507–Q0509).

Wound VAC (E2402) — prior authorization required.

Codes and Coding Notes

Covered HCPCS / J-codes (sample)HCPCSCovered

J2326	Injection, ravulizumab-cwvz (Ultomiris)
J1961	Injection, ceftriaxone sodium, per 250 mg
J2779	Injection, pembrolizumab, 1 mg
J2781	Injection, nivolumab, 1 mg
J3241	Injection, octreotide acetate, 50 mcg
S0189	Injection, long-acting antipsychotic, per 1 mg
J3121	Injection, trastuzumab, 10 mg
J2356	Injection, interferon gamma-1b, 10 mcg
J1299	Injection, azithromycin, 1 mg
Q9992	Injection, unspecified biosimilar (placeholder)

Covered CPT / HCPCS (Bariatric sample)CPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure with gastric bypass
43645	Laparoscopy, surgical; gastric restrictive procedure with gastrojejunal anastomosis
43659	Unlisted laparoscopy procedure, stomach
43770	Laparoscopic gastric bypass, with small intestine anastomosis
43775	Laparoscopy, gastric restrictive procedure; with gastric bypass
43842	Gastric restrictive procedure with endoscopic component
43845	Gastric restrictive revision
43846	Revision of gastric restrictive procedure (open)
43847	Revision of gastric restrictive procedure (laparoscopic)
43848	Removal of gastric restrictive device

1–10 of 11

1/2

Covered HCPCS / J-codes (Injectable oncology supportive drugs)HCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)

1–10 of 14

1/2

Neutral ICD-10 (Peripheral vascular / cardiovascular sample)ICD-10

I70.621	Atherosclerosis of native arteries of right leg with ulceration of calf
I70.622	... left leg
I70.623	... unspecified leg
I70.628	Atherosclerosis of other extremity arteries with ulceration
I70.629	... with ulceration, unspecified extremity

Neutral ICD-10 (Osteomyelitis sample)ICD-10

M86.061	Acute hematogenous osteomyelitis, right shoulder
M86.062	... left shoulder
M86.069	... unspecified shoulder
M86.071	Acute osteomyelitis, right forearm

Covered CPT (Neurophysiology sample)CPTCovered

95700	Electroencephalogram (EEG) routine
95711	Long-term EEG monitoring
95712	...
95713	...
95714	Inpatient video EEG
95715	Inpatient video EEG with interpretation
95716	...
95718	...
95720	EEG sleep study
95722	EEG sleep study with video

1–10 of 12

1/2

Covered CPT/HCPCS (Reconstructive / cosmetic sample)CPTCovered

17108	Destruction of benign lesion (cosmetic)
17999	Unlisted procedure, breast
21137	Reconstruction of facial bone
21138	Reconstruction of facial bone, complex

Covered HCPCS (Durable Medical Equipment sample)HCPCSCovered

A9279	Non-covered item (sample placeholder)
A9280	Non-covered item (sample placeholder)
A9900	Miscellaneous DME supply

Covered HCPCS (Enteral services)HCPCSCovered

B4034

Enteral formula, for home use

Covered HCPCS / Genetic testing (sample)HCPCSCovered

81410	Cystic fibrosis testing
81411	CPT broad genetic panel
81412	Targeted sequence analysis
S3854	Genetic test, specified

Neutral (Procedures and services sample)mixed

90283	Vaccine administration, complex
69710	Tonsillectomy code sample
L8614	Prosthetic implant

Covered HCPCS / J-codes (Injectable meds sample)HCPCSCovered

J2329	Briumvi
J1306	Lucentis
J2778	Ranibizumab (sample)
J3032	Vyepti
J3399	Zolgensma
J1449	Rolvedon (listed earlier)

Neutral HCPCS / Gene & CAR-T therapy codesHCPCS

Q2041	CAR T-cell therapy (sample)
Q2055	CAR T-cell therapy (sample)
C9399	Unclassified code for gene therapy

How Providers Must Submit and Notify

Prior Authorization

How to submit prior authorization

Submit prior authorization via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool), phone 800-366-7304, or fax 800-600-9007. Prior authorization is not required for emergency or urgent care. Out-of-network providers must request prior authorization for all procedures and services.

Online: UHCprovider.com → Prior Authorization and Notification tab (One Healthcare ID required).
Phone: 800-366-7304.
Fax: 800-600-9007.

Prior Authorization

Continuous glucose monitor prior authorization and benefit routing

Continuous glucose monitors require prior authorization when billed to the medical benefit and are routed by benefit type. Prior authorization is required for Type 2 diabetes diagnosis when billed on the medical benefit. Some product codes are pharmacy‑benefit items and are not reimbursable on the medical benefit — these must be submitted to OptumRx.

Affected codes include A4226, A9277, E2103, A4238, A9278, A4239, E0787, A9276, E2102.

Definitions, Thresholds, and Notes

Prior authorization — Prior authorization submission methods

Online portalUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID and select the Prior Authorization and Notification tab.

PhoneCall 800-366-7304 to submit prior authorization requests.

FaxFax prior authorization requests to 800-600-9007.

Emergency/urgent exceptionsPrior authorization is not required for emergency or urgent care.

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

Behavioral health services — Behavioral health services are managed by county Behavioral Health MCOs and are carved out

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone at 800-366-7304, or by fax at 800-600-9007.

SourceLink

On This Page

Cosmetic and reconstructive procedures — prior authorization required for listed CPT/HCPCS codes (examples include 11960, 14020, 15820–15823, 17106–17108, 17999, 21137–21139, 21172, 21175, 21179–21184, etc.).

Hysterectomy procedures (examples: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290) — prior authorization required.

Rhinoplasty and septoplasty (codes 30400, 30410, 30420, 30430, etc.) — prior authorization required.

Site of service (SOS) rule: prior authorization for services is required only when requesting the service in an outpatient hospital setting; some services are not required if performed at a participating ASC.

Codes marked with * indicate products not reimbursable on the medical benefit; submit those requests to OptumRx (OptumRx Help Desk 800-711-4555).

Prior Authorization

Prior authorization for reconstructive/cosmetic procedures and related codes

Prior authorization is required for cosmetic and reconstructive procedures. Reconstructive procedures that treat a medical condition may be covered; purely cosmetic procedures that only improve appearance require prior authorization and may be excluded.

Examples of CPT codes that require prior authorization (non‑exhaustive): 11960, 14020, 14021, 14061, 15820–15823, 15830, 15847, 15877–15879, 17106–17108, 17999, 21137–21139, 21172–21175, 21179–21184, 21230, 21235, 21256, 21275, 21280, 21282, 21295, 21740, 21742.
Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the number on the provider portal guidance.

Prior Authorization

Enteral services prior authorization

Enteral nutrition services and in‑home nutritional therapy require prior authorization.

Affected HCPCS codes include B4034, B4035, B4036, B4100, B4102–B4104, B4149, B4150, B4152–B4155, B4158–B4161, B9002, B9998.

Prior Authorization

Human milk bank prior authorization

Human milk bank services require prior authorization.

Affected code: T2101.
Submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Prior Authorization

Drug prior authorization instructions and listed J/Q codes

Certain injectable drug codes (J- and Q‑codes) require prior authorization. Submit drug prior authorization requests online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the number provided for specialty/drug review.

Many injectable medications listed require prior authorization (examples include J9000–J9999 series, J1932 reference, J0202, J0174, and numerous specific J/Q codes listed in the injectable medications table).
For prior authorization, submit requests online at UHCprovider.com → Prior Authorization and Notification. Or call 888-397-8129 for drug prior authorization assistance.

Note

Key HCPCS/J-code prior authorization references (J1932, J0202, J0174)

Reference codes that commonly indicate prior authorization requirements for specific drugs or therapies are included for provider billing and routing.

J1932 — referenced for prior authorization on multiple injectable entries.
J0202 — referenced for Lemtrada® and Leqembi® prior authorization routing.
J0174 — referenced for Leqembi® prior authorization (product billing code J0174).

Note

L-code listing (informational)

A wide L‑code listing for orthotics and prosthetics is provided for informational and prior authorization routing purposes. Prior authorization is required only for orthotics and prosthetic codes with a retail purchase or cumulative rental cost greater than $500.

Representative L‑codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0640, L0700, L0710, L0810–L0859, L2038, L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627–L2628, L3230, L3265, L3649, L3671, L3674, L3720, L3730, L3740, L3763–L3764, L3900–L3905, L3961, L3971, L3975–L3977, L3999–L4020, L4631, L5010–L5020, L8609–L8612, L8631, L8659, L8614 (cochlear device).
Guidance: prior authorization only when retail purchase or cumulative rental cost > $500; otherwise standard billing applies.

Prior Authorization

Spinal surgery prior authorization

Spinal surgery procedures require prior authorization.

Representative CPT codes include 22100–22102, 22110, 22112, 22114, 22206–22207, 22210, 22212, 22214, 22220, 22224, 22510–22515, 22532–22533, 22548, 22551, 22554, 22556, 22558, 22532–22558 series (see full policy for complete list).
Submit prior authorization via UHCprovider.com → Prior Authorization and Notification or call the prior authorization phone number.

Prior Authorization

Stimulators and implantable devices prior authorization

Implantable stimulators, neurostimulators, bone growth stimulators and related device implantation procedures require prior authorization.

Affected device and supply HCPCS/CPT examples include E0747–E0749, E0760, L8680, L8682, L8685–L8688, and CPT codes such as 61863–61886, 63650, 63655, 63685, 64553–64570, 64590, 43648, 43881–43882, 61863–61886 series.
Prior authorization required for implantation and related device supplies; submit requests via the Prior Authorization and Notification tool.

Prior Authorization

Stimulators prior authorization

Neurostimulator and other stimulator therapies require prior authorization and may have specific device L‑code or CPT mappings that must be submitted with the request.

Examples: bone growth stimulators, spinal cord/neurostimulators, peripheral nerve stimulators — CPT and L‑code listings are detailed in the policy (see section for full code mappings).
Follow device‑specific prior authorization processes; include device model, indication, and prior conservative therapy documentation when applicable.

Prior Authorization

Transplants prior authorization

Transplant and CAR T‑cell therapies require prior authorization and special case management routing.

For transplant and CAR T‑cell therapy services (including Abecma®, Breyanzi®, Kymriah™, Tecartus™, Yescarta™ and others), call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the notification number on the back of the member's ID card.
Transplant procedures and many associated CPT codes require prior authorization — contact the transplant case management team for pre‑determination and coordination.

Prior Authorization

Vein procedures prior authorization

Vein procedures for removal/ablation of saphenous trunks and named branches require prior authorization.

Affected CPT codes include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780 (and related codes listed in the full policy).
Submit prior authorization via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Prior Authorization

Wound vac prior authorization

Negative pressure wound therapy (wound VAC) requires prior authorization.

Affected HCPCS code: E2402.
Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Carve-out managementBehavioral health services are carved out and managed by the Behavioral Health Managed Care Organization (MCO) that covers the member's county of residence.

Contact pathFor details, contact the Member Services number on the back of the member's ID card.

ScopeThis carve-out note applies to behavioral health services listed in the policy; prior authorization processes for physical health services do not govern these services.

Cochlear implants — Cochlear implants: A medical device within the inner ear with an external portion to help persons with profound sensorineural deafness ac...

DefinitionCochlear implants: a medical device within the inner ear with an external portion to help persons with profound sensorineural deafness achieve conversational hearing.

Authorization stancePrior authorization required for cochlear implants as noted in the cochlear implant section and associated CPT/HCPCS codes.

Example codesCPT/HCPCS codes listed in the cochlear implant entry (see policy for complete code list).

Cosmetic and reconstructive — Cosmetic procedures: procedures that change or improve physical appearance without significantly improving or restoring physiological fun...

Cosmetic vs. reconstructiveCosmetic procedures change or improve physical appearance without significantly improving/restoring physiological function; reconstructive procedures treat a medical condition.

Authorization requirementPrior authorization required for cosmetic and reconstructive procedures listed in the policy (numerous CPT/HCPCS codes enumerated).

Exceptions noteSome reconstructive/cosmetic codes may have exceptions (e.g., 'Prior authorization not required when billed with the following'); check code-specific notes in the policy.

DME prior authorization threshold / prosthetics exclusion

DME cost thresholdPrior authorization required only when retail purchase or cumulative rental cost exceeds $500.

Prosthetics exclusionProsthetics are not considered DME; see orthotics and prosthetics section (L-codes) for prosthetic authorization rules.

How to obtain PAFollow the CPT/HCPCS code entries listed; pre-determination is recommended for related items where noted.

Reconstructive/cosmetic prior authorization note

Code exceptionsSome reconstructive/cosmetic procedure codes include notes indicating prior authorization may not be required when billed with specified diagnosis codes or conditions (e.g., Gender Dysphoria may apply).

Check code-level notesReview each listed CPT/HCPCS entry for 'Additional information' and 'Prior authorization not required when billed with the following' exceptions.

When in doubtSubmit a prior authorization request or contact Provider Services to confirm requirement for the specific code and diagnosis combination.

Enteral services — Enteral services: services and supplies for enteral nutrition (codes B4034, B4035, B4036, etc.).

DefinitionEnteral services: services and supplies for enteral nutrition (examples: B4034, B4035, B4036, B4100).

Authorization requirementPrior authorization required for enteral services and in‑home nutritional services as listed.

Example codesB4034, B4035, B4036, B4100, B4102, B4103, B4104 are included in the enteral/in‑home nutritional entries.

Genetic and molecular testing — Genetic and molecular testing: outpatient genetic/molecular tests requiring prior authorization; many CPT/HCPCS and proprietary test code...

ScopeGenetic and molecular testing (outpatient) requires prior authorization; the policy lists many CPT/HCPCS and proprietary test (U) codes.

Sample codesExamples include 81163, 81164, 81228, 81229, 81277, 81400–81405 and various U‑codes (see policy list).

SubmissionSubmit prior authorization via the Provider Portal or contact the number provided for drug/lab authorizations as noted in the policy.

Injectable medications prior authorization — Injectable medications listed require prior authorization

Authorization requirementInjectable medications listed with J‑/Q‑codes require prior authorization as enumerated in the policy.

Submission instructionsFor listed drugs, submit requests online via the Prior Authorization and Notification tool on UHCprovider.com or call the PA number provided in the drug section (see policy; e.g., 888-397-8129 for some drugs).

ExamplesNumerous J and Q HCPCS codes are listed across the injectable medication sections (see policy for full list).

Home health prior authorization scope — Prior authorization required only in outpatient settings, including the member's home

Setting scopePrior authorization for home health is required only in outpatient settings, which includes services provided in the member's home.

Relevant codesHome health codes cited include G0156, G0162, G0299, G0300, G0493–G0496 and S9122–S9124 (see policy).

Hospice and related servicesHospice (e.g., T2045) and other home-based services listed also require prior authorization per policy entries.

Lemtrada — Lemtrada

Lemtrada (J1932)Lemtrada is listed with HCPCS/CPT mapping (J1932) and requires prior authorization per the medication entries.

How documentedThe policy lists Lemtrada with repeated references under CPT/HCPCS codes indicating prior authorization instructions (see Lemtrada entries).

ActionSubmit prior authorization following the drug-specific submission instructions in the policy (Provider Portal or phone number indicated).

Leqembi / Leqembi® — Leqembi / Leqembi®

Leqembi (J0202 / J0174)Leqembi is referenced in the policy (J0202) and associated with HCPCS J0174 for prior authorization — the policy lists Leqembi with code mappings and PA instructions.

Code mappingPolicy entries repeat Leqembi and show J0202 and J0174 as associated codes for prior authorization reference.

Next stepFollow the drug-specific prior authorization submission process as outlined in the medication section of the policy.

drugs newly approved by the FDA that are tracked for pre-determination and review — Review at Launch Medication List

Review at Launch listThe policy references a 'Review at Launch Medication List' for new‑to‑market FDA‑approved drugs that are tracked for pre‑determination and review.

Pre-determination recommendationPre-determination is highly recommended for drugs on the Review at Launch Medication List.

Where to checkSee the policy's Review at Launch guidance and drug entries for how to submit pre‑determination or PA requests for these medications.

online submission method for PA requests — Prior authorization and Notification tool on the UnitedHealthcare Provider Portal

Online submission (recommended)Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Alternate phone contactIf needed, call the drug or PA phone numbers provided in the policy (examples: 888-397-8129 for some drugs; 866-889-8054 for advanced outpatient imaging).

Portal detailsLog in with One Healthcare ID and select the Prior Authorization and Notification tab on the dashboard to begin a submission.

Review at Launch Medication List — Review at Launch Medication List

List nameReview at Launch Medication List — a tracked list of newly approved FDA medications included in the policy for pre‑determination and review.

RecommendationPre‑determination is highly recommended for drugs on this list.

How to actProviders should check the Review at Launch section of the policy for current entries and follow the stated pre‑determination guidance.

Pre-determination — Pre-determination

DefinitionPre-determination: a recommended prior review (pre-authorization) process for drugs on the Review at Launch Medication List.

PurposeUsed to review coverage and authorization requirements for newly launched medications before initiating therapy.

RecommendationPre-determination is highly recommended for Review at Launch drugs per policy guidance.

Pre-determination is a recommended prior review process for drugs on the Review at Launch Medication List (phrase repeated in document).

Recommendation restatedPre-determination is a recommended prior review process for drugs on the Review at Launch Medication List (statement repeated in the policy).

ActionProviders should consider submitting pre‑determination requests for Review at Launch drugs via the Provider Portal.

ReferenceSee the Review at Launch section of the policy for current drug listings and instructions.

Advanced outpatient imaging — Advanced outpatient imaging procedures

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures that require notification/authorization.

Notification requirementHealth care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.

How to request PATo request prior authorization for advanced outpatient imaging, call 866-889-8054 or submit via the Provider Portal's Prior Authorization and Notification tool.

Site of service (SOS) - outpatient hospital — Site of service (SOS) - outpatient hospital: indicates when prior authorization is required based on outpatient hospital setting or perfo...

SOS outpatient hospital ruleSite of service (SOS) — Prior authorization is required only when requesting a service in an outpatient hospital setting; some services performed at a participating ASC may not require PA.

ImplementationCheck the policy's site‑of‑service notes for specific CPT codes and whether PA applies when performed in an outpatient hospital versus an ASC.

Provider actionIf scheduling in an outpatient hospital, follow PA submission steps in the policy (Portal, phone, fax).

Stimulators — Bone growth stimulator / Neurostimulator

Stimulators definedStimulators include bone growth stimulators and neurostimulators; implantation and related device codes are listed in the policy.

Authorization requirementPrior authorization required for stimulators (implantation and device codes such as E0747–E0760 and L8680–L8688 are listed).

ActionFollow device‑specific PA instructions in the stimulators section of the policy when submitting requests.

Prior authorization requirement — Procedures and surgeries that require prior authorization as noted in section headers (e.g., sleep apnea procedures, spinal surgery, tran...)

General PA ruleProcedures and surgeries identified in section headers (e.g., sleep apnea procedures, spinal surgery, transplants, stimulators) require prior authorization as noted.

ExamplesSleep apnea procedures, spinal surgery, stimulators and transplants are explicitly listed as requiring prior authorization in the policy.

Provider stepSubmit PA requests via the Provider Portal or the phone/fax numbers listed in the policy; follow code‑specific instructions where provided.

Ventricular assist device — Ventricular assist device (VAD)

VAD definitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle (policy describes the device and process).

Authorization requirementPrior authorization required for VADs; providers must call the notification number on the member's ID card and fax the Optum VAD form provided by the nurse.

Process noteFollow the policy's VAD notification and fax instructions for authorization and case management coordination.

Wound vac — Wound vac (negative pressure wound therapy) identified with HCPCS E2402

DefinitionWound vac (negative pressure wound therapy) is identified in the policy and associated with HCPCS code E2402.

Authorization requirementPrior authorization required for wound vac services and supplies listed (E2402).

Code referenceSee the policy entry for wound vac (E2402) for submission details.