CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements — Rocky Mountain Children's Health Plan (CHP)

This document lists services, CPT/HCPCS/J-codes and procedures that require prior authorization for participating and out-of-network providers serving members of the Rocky Mountain Children's Health Plan (CHP). It also explains submission methods and exceptions such as emergency/urgent care.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements — Rocky Mountain Children's Health Plan (CHP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via eviCore (www.evicore.com, 800-792-8750) or the UnitedHealthcare Provider Portal as directed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~300+Approximate listed codes

eviCorePrimary submission method

J9000-J9999Chemotherapy injectable range

ExemptEmergency/urgent care

20+Distinct code blocks

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Services and Codes Requiring Prior Authorization

Services requiring prior authorization (partial list)

Services and associated CPT/HCPCS codes that require prior authorization (partial list, examples from the policy):

Arthroscopy services (prior authorization required); examples: 29805, 29806, 29807, 29819, 29820-29828, 29870-29871.

Bariatric surgery and related obesity services (prior authorization required); examples: 43644-43645, 43770-43775, 43842-43848.

Breast reconstruction and related breast procedures (prior authorization required); examples: 19300, 19328, 19330, 19340, 19355, 19357, 19361, 19364, 19367-19371, 19380, 19396, S2066-S2068.

Cardiovascular / cardiology procedures (prior authorization required); example: 93459-93461 and other cardiovascular CPTs as listed.

Injectable chemotherapy drugs administered outpatient (prior authorization required); chemotherapy injectable HCPCS range J9000-J9999 and listed specific J/Q codes.

Partial code criteria

Code-level prior authorization and payer-specific benefit notes (partial list):

Q2026 — noted as 'Not a benefit for Commercial or RMHP Prime; Medicare only with Dx B20 AND E88.1' (payer-specific limitation).

Diagnostic/therapeutic CPTs (prior authorization required) — examples: 91065, 95012, 95060, 95065.

Durable medical equipment (DME) HCPCS examples requiring prior authorization — examples: K0891, A9520, K0898, A9999; note: prosthetics are not considered DME.

Prior authorization required criteria (partial)

Selected categories and code groups explicitly marked as requiring prior authorization (partial):

Enteral services and in-home nutritional/therapy items — prior authorization required; examples: E2298, B4149, B4150, B4152-B4155, B4157-B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216.

Experimental and investigational procedures — prior authorization required; examples: 64454, 64624, 64625, 91112, 91132, 91133.

Eye, ear, nose and throat (ENT) procedures — prior authorization required; examples: 68816, 69705, 69706, 69719, 69726-69730.

Genetic tests / lab services (some managed via eviCore) — prior authorization required; U-/M-series examples listed in the policy.

Prior authorization requirement

Genetic tests and laboratory services require prior authorization. Providers must submit authorization requests using the vendor or contact shown in the policy.

Genetic tests/lab services — Prior authorization required as noted in the policy; examples include many U-series and CPT genetic codes (see code lists).

How to obtain authorization — submit requests online at www.evicore.com or call 800-792-8750 (contact shown repeatedly in the genetic test sections).

Prior authorization requirement for listed genetic test codes

Extensive CPT/HCPCS genetic test codes listed in the policy require prior authorization; providers should use the contact methods shown to obtain authorization.

Listed genetic test codes require prior authorization — numerous U-series, T-series and other CPT/HCPCS codes are listed in the document (examples shown across chunks).

Contact for authorization — submit via eviCore portal or call 800-792-8750 per the instructions adjacent to the genetic code lists.

Prior authorization code lists and categories

Categories and associated code groups that require prior authorization (partial listing):

Genetic tests / molecular pathology — prior authorization required; examples: 83704, 83876, 83951, 83987, 84431, 86001, 86152-86153, 86305, 86343, 0368U.

Hearing/audio/vision services — prior authorization required; example codes include 0100T, 66989, 66991.

Home healthcare services — prior authorization required; examples: G0176, G0248-G0250, S9340-S9343, S9355, S9364-S9368.

Hyperbaric oxygen treatment — prior authorization required; example: G0277.

Injectable medications and certain J-/Q-codes — prior authorization required as listed (examples shown in the injectable medication section).

Prior authorization requirement by category/code

Selected procedure and service categories with prior authorization requirements and representative codes:

Medicine services — Prior authorization required; examples include 90587, 90626, 90627, 91113.

Musculoskeletal procedures — Prior authorization required; examples: 20957, 20972, 20973, 26556.

Obstetrical procedures — Prior authorization required; examples: 59897, 59898, S2400-S2401.

Orthotics and prosthetics L-codes — Prior authorization required; examples: L1499, L3649, L4000, L4070, L5010-L5060, L5100-L5160, L5200-L5280, L5301.

Prior authorization criteria for procedures and radiology

Prior authorization criteria for radiation therapy, advanced imaging, and selected procedure groups (summary):

Advanced outpatient imaging (Radiology, eviCore) — Prior authorization or notification required for participating physicians ordering advanced outpatient imaging; submit requests online at evicore.com or call 800-792-8750. Example CPTs listed in the Radiology sections.

Standard radiation therapy (2D/3D) — Prior authorization required only when provided with diagnoses in specified ranges (example ranges include C34.00-C34.92, C50.011, etc.); modality-specific codes (IMRT/IGRT/SRS/SBRT/proton) are listed and require authorization per the policy.

Pain management procedures — specific CPTs (e.g., 64451, 64461-64463) and modality codes tied to radiation therapy and pain services are identified for prior authorization in the document.

Coverage stance for listed procedures

Coverage stance and prior authorization expectations for selected procedures and service categories (as stated in the policy):

Radiology (advanced outpatient imaging, CT/MRI/MRA/PET and other nuclear medicine) — Prior authorization required; submit via eviCore or call 800-792-8750. See Radiology Prior Authorization and Notification for full CPT list.

Skin substitutes (multiple Q-codes such as Q4117, Q4118, Q4122, Q4123, etc.) — Prior authorization required.

Sleep and stimulator procedures (multiple 645xx, 636xx codes) — Prior authorization required as listed.

Spine surgery and other major surgery categories (multiple 22xxx and related CPTs) — Prior authorization required.

Transplants — Prior authorization required for transplant procedures; certain unclassified J/C codes associated with transplant medications require authorization through Optum Transplant.

Prior authorization coverage criteria (partial document)

Additional procedure-level prior authorization requirements and special channels (partial):

Urinary system procedures — Prior authorization required (policy notes the urinary system category is subject to prior authorization).

Vein procedures — Prior authorization required; example CPT for vein removal/ablation: 36471.

Unclassified J/C codes for certain drugs

For unclassified J-codes J3490, J3590 and C9399 (example products Amtagvi, Lenmeldy, Tecelra), prior authorization is required through Optum Transplant.
Providers must follow the Optum Transplant prior authorization route as specified in the policy for these unclassified codes.

See the coding code groups section of the policy for the full list of specific CPT/HCPCS codes referenced in these procedure categories.

CPT / HCPCS / Other Codes (Samples and Groups)

Arthroscopy — Covered CPT/HCPCSCPTCovered

29805	Arthroscopy, shoulder, diagnostic
29806	Arthroscopy, shoulder; with removal of foreign body
29807	Arthroscopy, shoulder; synovectomy
29819	Arthroscopy, knee, diagnostic
29820	Arthroscopy, knee, surgical
29821	Arthroscopy, knee; meniscectomy (medial OR lateral)
29822	Arthroscopy, knee; partial meniscectomy, each additional
29823	Arthroscopy, knee; meniscal repair
29824	Arthroscopy, knee; lateral meniscectomy
29825	Arthroscopy, knee; removal of loose body

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Bariatric surgery — Covered CPT/HCPCSCPTCovered

43644	Laparoscopy, gastric restrictive procedure; with gastric bypass
43645	Revision of gastric restrictive procedure
43770	Laparoscopy, gastric restrictive procedure; other than vertical-banded gastroplasty
43771	Laparoscopy, gastric restrictive procedure, with gastric bypass and Roux-en-Y
43772	Revision of gastric bypass
43773	Laparoscopy, gastric restrictive procedure; with gastric plication
43774	Laparoscopy, conversion of gastric banding
43775	Laparoscopy, gastric restrictive procedure; removal of adjustable gastric band
43842	Laparoscopy, gastric restrictive procedure; with partial gastrectomy
43843	Open gastric restrictive procedure; with gastric bypass

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Breast reconstruction — Covered CPT/HCPCSCPTCovered

19300	Mastectomy, partial
19316	Mastectomy, partial with axillary sampling (listed elsewhere)
19318	Other mastectomy codes (example in list)
19325	Mastectomy with immediate reconstruction
19330	Mastectomy, simple
19340	Immediate insertion of breast prosthesis
19342	Delayed insertion of breast prosthesis
19350	Nipple/areola reconstruction
19355	Breast reconstruction with latissimus dorsi flap
19357	Breast reconstruction with TRAM flap

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Chemotherapy injectable drugs & supportive agents — Covered HCPCS/Q-codesHCPCSCovered

J9000-J9999	Range: chemotherapy injectable drugs (prior authorization required)
J0640	Leucovorin, per mg
J0641	Levoleucovorin, per mg (J0641)
J0642	Levoleucovorin, per mg (J0642)
J1950	Leuprolide acetate (Lupron Depot)
J0885	Injection, of biosimilar/antineoplastic (example)
J1449	Chemotherapy/biologic injection
J1932	Injection, trastuzumab-anns
J1954	Injection, pertuzumab
A9607	Lutetium Lu 177 (radiopharmaceutical)

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Cochlear / Auditory implants — Covered CPT/HCPCSmixedCovered

69930	Cochlear implantation procedure
L8619	Cochlear implant internal device
L8627	Cochlear implant external processor
L8629	Cochlear implant accessory

Reconstructive / Cosmetic (selected) — Covered CPTCPTCovered

21100-21296	Craniofacial/reconstructive surgery CPT range examples
21497	Excision/repair complex facial structures
21740-21743	Reconstruction of forehead/temples
15769-15879	Large flap/complex wound closure and related codes
19316-19350	Breast-related reconstructive codes (additional examples)
21120-21210	Facial fracture/reconstruction range examples
30400-30435	Rhinoplasty and nasal reconstruction codes
54401-54417	Urologic reconstructive procedures examples
56805	Vaginal reconstructive procedure
67900	Blepharoptosis repair/related eyelid procedures

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Orthotics / Prosthetics (examples) — Covered HCPCS L-/K-HCPCSCovered

K0001-K0899	Durable medical equipment orthotics examples (range; select examples shown)
L0000-L9999	Orthotic/prosthetic L-code series (examples shown elsewhere)
B4149-B4216	Enteral nutrition supplies (examples shown)

Genetic tests / U-series — Covered (selected)CPTCovered

0001U-0134U	U-series and other temporary genetic CPT codes (many U-series codes shown)
0336U	Example U-code shown
0339U	Example U-code shown
0340U	Example U-code shown

Medical & Surgical Supplies Q-codes — Covered (examples)HCPCSCovered

Q2041	Skin substitute Q-code example
Q5101	Injectable medication Q-code example
Q5125	Injectable medication Q-code example
Q5133	Effective Oct.1,2024: Prior auth required for Q5133
Q5135	Effective Oct.1,2024: Prior auth required for Q5135

Selected procedure CPT examples — CoveredCPTCovered

21146	Mandibular/maxillofacial reconstructive example
21147	Mandibular procedure example
21150	Facial skeletal procedure example
21151	Maxillofacial procedure example
21154	Osteotomy/reconstruction example
21155	Reconstructive procedure example
21159	Reconstruction example
21160	Reconstruction example
21180	Maxillofacial reconstruction example
21181	Facial reconstruction example

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Additional selected CPT codes — CoveredCPTCovered

21497	Facial reconstruction
21740	Forehead reconstruction
21742	Forehead reconstruction
21743	Forehead reconstruction
96904	Light therapy code example
96920	Dermatologic procedure
96921	Dermatologic procedure
96922	Dermatologic procedure
15792	Complex flap procedure
15793	Complex flap procedure

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Home health / Hyperbaric / Injectables — Covered (examples)HCPCSCovered

G0176	Home health related service
G0248	Home health related service
G0249	Home health related service
G0250	Home health related service
G0277	Hyperbaric oxygen therapy
S9340	Home healthcare supply
S9341	Home healthcare supply
S9342	Home healthcare supply
S9343	Home healthcare supply
S9355	Home healthcare supply

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Medical & Surgical supply C-/Q-/other codes — Covered (examples)HCPCSCovered

C1761	Surgical supply example
C1772	Surgical supply example
C1821	Surgical supply example
Q4282	Skin/biologic supply
C1891	Surgical supply
C2626	Surgical supply
C9352	Surgical supply
C9353	Surgical supply
C9354	Surgical supply
C9355	Surgical supply

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Orthotics/Prosthetics L-codes — Covered (selected)HCPCSCovered

L1499	Unlisted orthotic procedure
L3649	Oral appliance
L4000	Prosthetic device
L4070	Prosthetic component
L5010	Prosthetic lower limb
L5020	Prosthetic lower limb
L5050	Prosthetic component
L5060	Prosthetic component
L5100	Prosthetic upper limb
L5105	Prosthetic component

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Selected drug HCPCS/J-codes — Covered (examples)HCPCSCovered

J0174	Prior auth required effective Aug.1,2023
J1280	Drug example
J3290	Drug example
J3394	Drug example listed under transplants

Transplant and related codes — Neutral/Informationalmixed

J3490	Unclassified drug code — PA required for some products
J3590	Unclassified drug code — PA required for some products
C9399	Unclassified drug code — PA required for some products
S2053	Transplant related supply
S2054	Transplant related supply
S2055	Transplant related supply
S2060	Transplant related supply
S2061	Transplant related supply
S2065	Transplant related supply
S2102	Transplant related supply

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Genetic/Molecular pathology CPT examples — Covered with criteriaCPTCovered

81162	Genetic test example
81163	Genetic test example
81164	Genetic test example
81165	Genetic test example
81166	Genetic test example
81167	Genetic test example
81173	Genetic test example
81174	Genetic test example
81185	Genetic test example
81283	Genetic test example

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Additional CPT/HCPCS examples (mixed) — Neutralmixed

69930	Cochlear implant procedure (also listed in covered group)
30400-30435	Rhinoplasty code range (examples shown elsewhere)
54401-54417	Urologic surgery examples (also listed)

Q-/C-/other codes (continued) — CoveredHCPCSCovered

Q4117	Skin substitute
Q4118	Skin substitute
Q4122	Skin substitute
Q4123	Skin substitute
Q4132	Skin substitute
Q4133	Skin substitute
Q4141	Skin substitute
Q4146	Skin substitute
Q4147	Skin substitute
Q4148	Skin substitute

Example implantable devices / stimulators — CoveredHCPCSCovered

E0764	Stimulation device example
E0770	Stimulation device example
E0783	Stimulation device example
E0830	Equipment example

Enteral services — Covered (examples)HCPCSCovered

B4149	Enteral feeding supply example
B4150	Enteral feeding supply example
B4152	Enteral feeding supply example
B4153	Enteral feeding supply example
B4154	In-home nutritional supply

Example miscellaneous procedure/drug codes — CoveredmixedCovered

J2357	Drug example
J3241	Drug example
J3358	Drug example
J9311	Drug example
J9312	Drug example
Q5115	Q-code drug example
J1961	Drug example
J2765	Drug example

Provider-notes / PA-effective codes — Infomixed

J0174	Prior authorization required effective Aug.1,2023 (see notes)
Q5133	Prior authorization required effective Oct.1,2024
Q5135	Prior authorization required effective Oct.1,2024

Selected CPT ranges & examples — CoveredCPTCovered

15769-15879	Flap and complex wound repair CPT range (examples shown)
19316-19350	Additional breast procedure CPT examples
21120-21210	Facial/maxillofacial CPT range examples
30400-30435	Rhinoplasty CPT range examples
54401-54417	Urologic CPT range examples

U-series and genetic — Covered (many U codes listed)CPTCovered

0001U	Genetic test example
0002U	Genetic test example
0003U	Genetic test example
0004M	Genetic test example
0005U	Genetic test example
0006M	Genetic test example
0007M	Genetic test example
0011M	Genetic test example
0012M	Genetic test example
0013M	Genetic test example

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Additional DME/E-series examples — CoveredHCPCSCovered

E0764	DME example
E0770	DME example
E0783	DME example
E0830	DME example
E0849	DME example
E0855	DME example
E0920	DME example
E0930	DME example

Sample CPT/HCPCS codes requiring PA — CoveredmixedCovered

J3399	Unclassified drug — PA applies for some products
C9399	Unclassified drug — PA applies for some products
J3490	Unclassified drug — PA applies for some products
J3590	Unclassified drug — PA applies for some products

How to Submit Requests and Operational Notes

Prior Authorization

How to Submit Prior Authorization Requests

Prior authorization is required for many specialty referrals and for services managed by eviCore. Submit requests for eviCore-managed services online at www.evicore.com (sign in) or call 800-792-8750. For radiology prior authorization and selected genetic testing, follow eviCore instructions. Behavioral health prior authorization: call 888-282-8801. Notification by admitting facility: phone 800-416-2157, option 4 or 970-248-5197. Prior authorization is not required for emergency or urgent care.

Use UnitedHealthcare Provider Portal for many PA requests: UHCprovider.com -> Sign In -> Prior Authorization and Notification tab.
Non-participating providers may fax requests and documentation to 800-262-2567 or 970-255-5681.

Prior Authorization

Diagnostic/therapeutic prior authorization

Diagnostic and therapeutic services (including allergy testing/therapy codes such as 91065, 95012, 95060, 95065 and selected pathology/therapeutic codes listed) require prior authorization. For participating providers, submit these requests through the appropriate channel (eviCore when noted) or via the UnitedHealthcare Provider Portal.

Key Terms and Submission Channels

Emergency/urgent care — Prior authorization not required for emergency or urgent care.

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

Submission methods (non-emergent)Online portal, fax, eviCore phone/web, behavioral health phone, admitting facility notification

ScopeApplies to participating UnitedHealthcare Community Plan of Colorado Rocky Mountain CHP providers

Out-of-network provider prior authorization — Out-of-network providers must request prior authorization.

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

Fax option for non-participating providers

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements — Rocky Mountain Children's Health Plan (CHP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests via eviCore (www.evicore.com, 800-792-8750) or the UnitedHealthcare Provider Portal as directed.

SourceLink

On This Page

Medical and surgical supplies (multiple C-/Q-/P-codes) — prior authorization required as listed in the supplies block.

Examples of diagnostic/therapeutic codes requiring PA: 91065, 95012, 95060, 95065, 88375, 88749, 89240, G0429.

Note

Q-code benefit notes

Q-codes have specific benefit restrictions. Some are limited to Medicare or specific diagnoses (for example certain Q20xx codes and lipodystrophy/HIV indications). Verify member coverage and product-specific benefit rules before submitting a PA.

Q2026/Q2028/Q2029: product- and plan-specific limitations; some Q-codes not a benefit for Commercial or RMHP Prime.
Medicare-only coverage examples require specific diagnoses (e.g., B20 AND E88.1).

Prior Authorization

ENT procedures — prior authorization required

ENT procedures and related CPT/HCPCS codes listed in the procedures table require prior authorization. Examples include procedures with codes 68816, 69705–69730 and related codes shown in the ENT section. Submit PA via the UnitedHealthcare Provider Portal or other specified vendor channel.

Selected ENT codes requiring PA: 68816, 69705, 69706, 69719, 69726–69730, 69730 and others listed in the ENT entries.

Prior Authorization

Genetic tests/lab services — prior authorization required

Genetic tests and many laboratory services require prior authorization. A large list of CPT/HCPCS and proprietary molecular codes (0001U–0165U and numerous others and standard lab CPTs) are subject to PA. Many of these are managed by eviCore; submit online at www.evicore.com or call 800-792-8750.

Examples of genetic/molecular codes requiring PA: 0001U, 0004M, 0005U, 0006M, 0007M, 0011M–0013M, 0016M, 0355U, 0356U, 0362U, 0364U, 0413U, 0379U, 0380U, 0403U–0411U, and many additional U-/T- codes listed in the genetic services sections.
For eviCore-managed tests: please submit at www.evicore.com or call 800-792-8750.

Prior Authorization

Prior authorization required for listed genetic test codes

Certain listed genetic test codes specifically require prior authorization. Refer to the genetic services list and contact eviCore for submission. A phone option (800-792-8750) is available for assistance.

Codes with explicit PA requirement examples: 81441, 81449, 81451, 81456, and numerous U-/T- codes (see genetic codes list).
If directed to eviCore, submit online at www.evicore.com or call 800-792-8750.

Note

Authorization contact

Authorization contacts and submission channels vary by service type: use the UnitedHealthcare Provider Portal (UHCprovider.com) for many prior authorizations (call 866-889-8054 for Portal assistance), eviCore for specified specialties and radiology (www.evicore.com, 800-792-8750), behavioral health at 888-282-8801, and facility notifications at 800-416-2157 (option 4) or 970-248-5197. Non-participating providers may fax to 800-262-2567 or 970-255-5681.

UnitedHealthcare Provider Portal: UHCprovider.com -> Prior Authorization and Notification tab; Portal support 866-889-8054.
eviCore: www.evicore.com or 800-792-8750 for managed specialties, radiology and many genetic tests.
Behavioral health: 888-282-8801.
Facility admission notification: 800-416-2157 (option 4) or 970-248-5197.

Prior Authorization

Medicine services - prior authorization

Medicine services (vaccines, biologics, therapeutics and selected procedures) require prior authorization as listed. Examples include vaccine/medicine codes and related procedures; check the medicine services list for the specific CPT/HCPCS codes and follow the specified PA channel.

Examples of medicine codes requiring PA: 90587, 90626, 90627, 91113, and listed medicine-related procedure codes.
Follow submission instructions in the medicine services section; some products may require specialty drug channels or specific vendor PAs.

Prior Authorization

Musculoskeletal & Obstetrical procedures - prior authorization

Musculoskeletal and obstetrical procedures (including listed surgical and implant codes) require prior authorization. Examples include musculoskeletal codes 20957, 20972, 20973 and obstetrical codes 59897, 59898 as well as S-series maternity procedure codes. Submit via the UnitedHealthcare Provider Portal or other indicated channels.

Musculoskeletal examples: 20957, 20972, 20973.
Obstetrical examples: 59897, 59898, S2400–S2411 series codes.

Prior Authorization

Orthotics & Prosthetics - prior authorization

Orthotics and prosthetics items require prior authorization. Many L-series prosthetic and orthotic HCPCS codes are listed and require PA prior to fabrication or initial fitting. Check the orthotics/prosthetics code list and submit authorization requests through the Provider Portal or the designated PA channel.

Examples of orthotics/prosthetics codes requiring PA: L1499, L3649, L4000, L4070, L5010–L5060, L5100–L5160, L5200–L5230, L5250, L5270, L5280, L5301, L5210 etc.

Prior Authorization

Pain management codes / prior authorization

Pain management procedures (including nerve blocks and neuromodulation codes) require prior authorization. Examples include CPT codes 64451, 64461–64463 and related series; additional procedure-level pain codes (64490–64495 series) are shown and may map to radiation/IGRT/IMRT coding in the radiation section for modality-specific review. Follow the PA routing indicated for pain management.

Pain management examples: 64451, 64461, 64462, 64463 and series 64490–64495 where applicable.
Some pain procedures may require clinical documentation supporting medical necessity and prior conservative treatments.

Prior Authorization

Radiation therapy prior authorization

Radiation therapy and related advanced radiation procedures (IMRT, IGRT, proton beam, Y90 microspheres and device-based therapy) require prior authorization. Codes and mapping (for example to 77520–77525, 77331, 70460–70480, G60xx series, and Y90) are listed. For participating providers submit radiation and radiology PAs using the UnitedHealthcare Provider Portal or as directed; radiology cases managed by eviCore must be submitted at www.evicore.com or by calling 800-792-8750. For Portal assistance call 866-889-8054.

Radiation examples: IGRT/IMRT/proton beam mappings and CPT/HCPCS listed (e.g., 77520–77525, 77331, 70460–70480, G6001–G6017 series, Y90).
Radiology prior authorization details and code lists available via eviCore or Radiology Prior Authorization and Notification guidance.

Note

Alternate prior authorization submission instruction (UHC portal referenced)

Alternate submission: many prior authorizations may be submitted via the UnitedHealthcare Provider Portal at UHCprovider.com. Where the policy or code list references eviCore or other vendors, follow that vendor’s online submission process (e.g., www.evicore.com for eviCore-managed services). Portal support: 866-889-8054. eviCore support: 800-792-8750.

UHC Provider Portal: UHCprovider.com -> Sign In -> Prior Authorization and Notification tab.
eviCore (for specialty radiology/genetics and other managed services): www.evicore.com or 800-792-8750.

Fax requests to 800-262-2567 or 970-255-5681

Portal instructionUse UHCprovider.com with One Healthcare ID for portal submissions

prosthetics vs DME — Prosthetics are not DME.

Prosthetics vs DMEProsthetics are not considered DME — see separate guidance.

DME PA requirementDurable medical equipment (DME) — prior authorization required for listed DME HCPCS codes (examples: K0891, A9520, K0898, A9999).

Example HCPCS entriesAdditional DME/related codes listed in policy excerpts

Q-code Medicare limitation — Certain Q-codes limited to Medicare with specific diagnoses.

Q-code Medicare limitationSome Q-codes limited to Medicare only when billed with Dx B20 (HIV) AND E88.1 (lipodystrophy).

Payer benefit note exampleQ2026 marked 'Not a benefit for Commercial or RMHP Prime' in the policy.

Other Q-code referencesQ2028 and Q2029 also appear in the Q-code section with payer-specific notes.

eviCore reference

eviCoreeviCore healthcare referenced as submission and management vendor for genetic tests and radiology (www.evicore.com; 800-792-8750).

eviCore-managed codesMultiple U-series and genetic test codes are identified as eviCore items in the policy.

How to submit to eviCoreProviders instructed to submit requests online at evicore.com or call 800-792-8750.

Prior authorization required notation in table (notation '1')

Notation '1' in code tableTable notation '1' = Prior authorization required for the listed genetic tests/lab services.

Example codes with notationMultiple genetic/U-series codes in the table are marked with notation '1' indicating PA required.

Contact for PAProviders can call 800-792-8750 for authorization assistance (per table directions).

Prior authorization — general notation

Prior authorization — general'Prior authorization required' is the status applied to many listed services and codes throughout the document.

ExamplesGenetic tests/lab services, selected DME, enteral services, medicine services and orthotics/prosthetics are annotated as requiring PA.

Primary submission channelMost PA requests directed to eviCore or UnitedHealthcare Provider Portal depending on service type.

unclassified/temporary codes — Temporary/unclassified codes require PA for specified products.

Temporary/unclassified codes PAUnclassified/temporary codes (e.g., C9399, J3490, J3590) require prior authorization for specified products listed in the policy.

Examples of products requiring PA under unclassified codesAmvuttra, Fylnetra, Lupaneta Pack, Nulibry, Recovi, Riabni, Rivfloza, Skyrizi, certain white blood cell colony stimulating factors, Veopoz.

Code-specific notesPolicy lists code mappings and special PA conditions for several J- and Q-codes in this section.

Prior authorization — general

Prior authorization — generalPrior authorization required for many genetic test and lab service CPT/HCPCS codes listed in the document.

Submission instructionSubmit requests online at www.evicore.com to sign in, or call 800-792-8750.

Table and code listsExtensive U-series and related CPT codes are enumerated with PA indicated.

Advanced outpatient imaging notification — Radiology requires notification prior to scheduling

Advanced outpatient imaging notificationCare providers ordering an advanced outpatient imaging procedure are responsible for providing notification prior to scheduling the procedure.

Radiology PA submissionSubmit radiology PA requests online at www.evicore.com or call 800-792-8750; see Radiology Prior Authorization and Notification for CPT codes.

Alternate channel for some imagingFor select implant/related codes use UnitedHealthcare Provider Portal or call 866-889-8054 as noted.

Prior authorization submission methods (evicore, phone, UHC portal variants)

Primary submission via eviCoreSubmit requests online at www.evicore.com (sign in) or call 800-792-8750.

UnitedHealthcare Provider PortalUse UHCprovider.com (One Healthcare ID) Prior Authorization and Notification tool; call 866-889-8054 for portal assistance where indicated.

Other channelsFax for non-participating providers (800-262-2567 or 970-255-5681); behavioral health phone 888-282-8801; admitting facility notification phone 800-416-2157 option 4 or 970-248-5197.

How to Obtain Prior Authorization: online via evicore.com sign-in or phone 800-792-8750

eviCore onlineHow to obtain prior authorization: submit requests online at www.evicore.com (sign in).

eviCore phoneOr call eviCore at 800-792-8750 for assistance or to obtain authorization.

ContextThese instructions are repeated across the genetic tests/lab services and radiology sections.

UHCprovider.com / 866-889-8054 — alternate submission

UHC Provider Portal alternativeAlternate submission: use UnitedHealthcare Provider Portal at UHCprovider.com (sign in with One Healthcare ID).

Portal phone supportOr call 866-889-8054 for details and assistance where the portal is specified.

When to use portalSome procedures and implant-related codes direct providers to submit via the UHC provider portal instead of eviCore.

Optum Transplant — required channel for certain unclassified J/C codes

Optum Transplant required channelFor unclassified codes J3490, J3590, and C9399 (examples: Amtagvi, Lenmeldy, Tecelra) prior authorization is required through Optum Transplant.

Examples of impacted drugsAmtagvi, Lenmeldy and Tecelra are listed as requiring Optum Transplant PA when billed to unclassified codes.

Where notedThis requirement is explicitly repeated in the transplant and unclassified code sections of the policy.

Optum Transplant PA requirement for specific unclassified J-codes

Optum Transplant PA requirementPrior authorization through Optum Transplant is required for specific unclassified J-codes (J3490, J3590, C9399) when used for designated products.

Designated products examplePolicy cites Amtagvi, Lenmeldy, Tecelra and others that will require Optum Transplant PA under these unclassified codes.

Cross-referenceSee the Procedures and Services transplant section for additional context and instruction.