CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for participating providers — code and service list (excerpt)

List of services and CPT/HCPCS codes that require prior authorization for participating providers and instructions for submitting requests; applies to in-network and out-of-network providers except for emergency/urgent care.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for participating providers — code and service list (excerpt)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UHCprovider.comportal

877-842-3210prior auth phone

888-397-8129chemo phone

Manycodes listed

$500DME threshold

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 Requiring Prior Authorization

inv-01: Prior authorization required for listed services and codes

Services and items in this document require prior authorization as indicated below.

Prior authorization required for the services and codes listed in this document; submission must follow provider portal or phone instructions where specified.

Examples of services requiring prior authorization

Abortion procedures — CPT codes listed (e.g., 59830, 59850, 59851, 59852) require prior authorization.
Continuous glucose monitors and supplies — A4238, A4239, A9274/A9276 require prior authorization; some CGMs may be covered under pharmacy benefits and should be redirected per PDL/Prime Therapeutics guidance.
Durable medical equipment (DME) codes such as E0265, E0266, E0328 require prior authorization.
BRCA genetic testing — CPT codes 81162, 81163, 81164, 81165 require prior authorization.
Cancer supportive services — selected colony-stimulating factor drugs (e.g., J1442) require prior authorization for outpatient administration.

inv-02: Prior authorization criteria (partial)

Partial list of services and specific CPT/HCPCS codes that require prior authorization (excerpt).

Enteral in‑home nutritional therapy (enteral or via gastrostomy) — prior authorization required for B‑codes: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998.

Functional endoscopic sinus surgery (FESS) — prior authorization required for CPT codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Home health services including extended nursing (PDN) — prior authorization required in outpatient settings (including the member's home); example codes: G0299, T1000, G0300, S9123, S9124.

Injectable medications — numerous J/Q codes listed require prior authorization; providers should submit via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the specified phone number; special rules apply for unclassified/temporary codes and Review at Launch drugs.

inv-03: Partial prior authorization criteria

Additional partial criteria and conditions that affect prior authorization requirements.

Orthotics and prosthetics: prior authorization is required only for orthotic and prosthetic items with a retail purchase or cumulative rental cost above the specified threshold (see threshold node).

Radiology (advanced outpatient imaging and nuclear medicine): prior authorization required; providers must submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.

Proton beam therapy — prior authorization required for CPT codes 77520, 77522, 77523 (and related codes).

Personal care services and pediatric day services — prior authorization required (example personal care service code: T1019).

Radiology - PET scans — prior authorization required for PET-related codes such as 78608, 78813, A9515, A9587; see portal/phone submission instructions for radiology authorizations.

inv-04: Stated coverage and prior authorization requirements

Notable coverage statements and operational instructions regarding prior authorization for high‑impact services.

Stated coverage and prior authorization requirements

Ventricular assist devices (VAD) — prior authorization required; VAD devices and supplies are not covered. For prior authorization call the notification number on the back of the member's health plan ID card and fax the nurse‑provided form to Optum VAD Case Management Team at 855-282-8929.
Transplant and CAR T‑cell therapy — prior authorization/notification required; contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number on the member's ID card.
Radiology prior authorization process — use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call 866-889-8054 for advanced outpatient imaging and PET scans.
Additional high‑impact services that require prior authorization include PET scans, many advanced outpatient radiology procedures, sinuplasty, rhinoplasty, sleep apnea procedures, spinal surgeries, stimulators, transplants/CAR T, VADs, and vein procedures; see respective code listings and portal/phone instructions.

Codes and Coding Notes

Abortion proceduresCPTCovered

59830	Abortion-related procedure code listed for prior authorization
59850	Abortion-related procedure code listed for prior authorization
59851	Abortion-related procedure code listed for prior authorization
59852	Abortion-related procedure code listed for prior authorization

Genetic testingCPTCovered

81162	BRCA genetic testing code requiring prior authorization
81163	BRCA genetic testing code requiring prior authorization
81164	BRCA genetic testing code requiring prior authorization
81165	BRCA genetic testing code requiring prior authorization

Colony-stimulating factors and supportive cancer agentsHCPCSCovered

J1442	Filgrastim (Neupogen) - colony-stimulating factor requiring prior authorization
Q5101	Pegfilgrastim (Neulasta) - requires prior authorization
J2506	Pegfilgrastim-apgf (Nyvepria) - requires prior authorization

Continuous glucose monitor codesHCPCSCovered

A4238	Continuous glucose monitor supply code requiring prior authorization
A4239	Continuous glucose monitor supply code requiring prior authorization
A9274	CGM supply code

DME codesHCPCSCovered

E0265	Durable medical equipment code listed requiring prior authorization
E0266	Durable medical equipment code listed requiring prior authorization
E0328	Durable medical equipment code listed requiring prior authorization

Injectable medication J/Q codes (partial list)HCPCS

J3262	Actemra®
J0801	Acthar® / Acthar® (listed multiple times)
J0791	Adakveo®
J0172	Aduhelm® / Aduhelm J0172
J1426	Amondys 45
J0225	Amvuttra™
Q5121	Avsola™
J0597	Berinert
J0585	Botulinum toxin
J0567	Brineura™

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Joint replacement / orthopedic CPT codes (partial)CPT

27130	Total hip replacement (example code listed)
27132	Hip arthroplasty
27412	Knee arthroplasty
27447	Knee replacement (example)
29866	Arthroscopic procedure (listed under joint replacement)

FESS CPT codesCPT

31240	Functional endoscopic sinus surgery (FESS)
31253	FESS related code
31254	FESS related code
31255	FESS related code

Orthognathic surgery CPT codes (partial)CPT

21121	Orthognathic surgery code
21123	Orthognathic surgery code
21125	Orthognathic surgery code
21127	Orthognathic surgery code

Orthotics and prosthetics L-codes (partial)HCPCS

L0170	Orthotics/prosthetics (example)
L0464	Orthotics/prosthetics (example)
L0482	Orthotics/prosthetics (example)
L0484	Orthotics/prosthetics (example)
L0486	Orthotics/prosthetics (example)

Orthognathic surgery (partial)CPTCovered

21146	Orthognathic surgery CPT code listed
21147	Orthognathic surgery CPT code listed
21150	Orthognathic surgery CPT code listed

Orthotics and prosthetics (partial)HCPCSCovered

L0170	Orthotic/prosthetic HCPCS L-code listed
L0464	Orthotic/prosthetic HCPCS L-code listed
L0482	Orthotic/prosthetic HCPCS L-code listed

Proton beam therapy (partial)CPTCovered

77520	Proton beam therapy CPT code
77522	Proton beam therapy CPT code
77523	Proton beam therapy CPT code

Radiology - PET scansmixedCovered

78608	PET scan CPT/HCPCS code listed
78813	PET scan CPT/HCPCS code listed
A9515	PET scan HCPCS code listed

ENT procedures (partial)CPTCovered

30400	Rhinoplasty CPT code listed
30410	Rhinoplasty CPT code listed
31295	Sinuplasty CPT code listed

Radiology - PET scansCPT | HCPCSCovered

78608	PET/related nuclear medicine
78813	PET/related nuclear medicine
A9515	Radiopharmaceutical
A9587	Radiopharmaceutical

CAR T-Cell Therapy codesHCPCSCovered

Q2041	CAR T-cell therapy HCPCS
Q2042	CAR T-cell therapy HCPCS
Q2056	CAR T-cell therapy HCPCS
Q2057	CAR T-cell therapy HCPCS

VAD procedure codesCPT | HCPCSCovered

33975	Ventricular assist device-related code
33976	Ventricular assist device-related code
33979	Ventricular assist device-related code
33981	Ventricular assist device-related code
33982	Ventricular assist device-related code
33983	Ventricular assist device-related code

Vein proceduresCPTCovered

36473	Vein removal/ablation
36475	Vein removal/ablation
36478	Vein removal/ablation
37700	Vein procedures

DME retail purchase/cumulative rental threshold

Threshold amount$500 retail purchase or cumulative rental cost

Applies toSpecified DME HCPCS/CPT codes listed in the DME section (authorization required only for codes with retail purchase or cumulative rental cost)

How evaluatedPrior authorization required when the retail purchase price or cumulative rental cost for the listed code meets or exceeds $500

How to Obtain Authorization and Provider Contacts

Prior Authorization

How to obtain prior authorization

For prior authorization, please submit requests online by using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal. Go to UHCprovider.com and click the UnitedHealthcare Provider Portal button in the top right corner. Then select the Prior Authorization and Notification tile on your Provider Portal dashboard. Or call the phone numbers listed below for specific services.

General prior authorization phone (UnitedHealthcare Community Plan portal support): 888-397-8129
Radiology advanced outpatient imaging prior authorization: 866-889-8054
Chemotherapy and many injectable medication prior authorizations: 888-397-8129
Transplant and CAR T-cell therapy case management: 888-936-7246 or the notification number on the back of the member's ID card
Ventricular Assist Device (VAD): Call the notification number on the back of the member's ID card; then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929
Some Continuous Glucose Monitors (CGMs) may be covered under the pharmacy benefit; if the brand appears in the plan's PDL Diabetic Supplies list, redirect to Prime Therapeutics State Government Solutions, LLC at 1-800-424-xxxx

Key Terms and Thresholds

Prior authorization definition

DefinitionPrior authorization: A payer requirement to obtain approval before certain services or supplies are provided (not required for emergency or urgent care)

Submission methodsOnline via UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone (see policy for phone numbers)

ScopeApplies to participating in-network and out-of-network providers (out-of-network must request authorization for all procedures and services except emergent/urgent care)

DME retail purchase/cumulative rental threshold: $500

Amount$500

ContextDME retail purchase or cumulative rental cost threshold that triggers prior authorization for listed DME codes

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for participating providers — code and service list (excerpt)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization online via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 877-842-3210.

SourceLink

On This Page

Joint replacement (total hip/knee) — prior authorization required for multiple CPT codes (examples include 27130, 27412, 27446, 27447, 29866).

Non‑emergent air ambulance transport — prior authorization required for A0430 and A0435.

Orthognathic surgery — prior authorization required for CPT codes including 21121, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151.

Orthotics and prosthetics — prior authorization required for listed L‑codes (e.g., L0170, L0464, L0482, L0484, L0486) subject to retail/cumulative thresholds where noted.

Orthotics/prosthetics prior authorization threshold

Threshold amountMore than $500 retail purchase or cumulative rental cost

Applies toOrthotics and prosthetics L-codes and related HCPCS codes listed in the orthotics/prosthetics section

Authorization conditionPrior authorization required when retail purchase or cumulative rental cost exceeds $500

Prior Authorization

Chemotherapy prior authorization contact

For chemotherapy prior authorization requests, submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) by selecting the Prior Authorization and Notification tile. If you prefer phone assistance, call 888-397-8129.

Prior Authorization

CGM pharmacy benefit redirection

Certain continuous glucose monitors (CGMs) may be covered under the pharmacy benefit rather than as DME. Check the plan's PDL Diabetic Supplies list (PDL Diabetic Supplies.pdf). If the requested brand is listed in the 'Drugs on PDL' column, redirect the request to Prime Therapeutics State Government Solutions, LLC at 1-800-424-xxxx.

Prior Authorization

How to obtain prior authorization (partial)

Injectable medications (including many J-codes and specialty products) require prior authorization. For drugs listed on the plan's Review at Launch/New-to-Market Medication List, pre-determination is highly recommended. Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129. For certain drug codes and exceptions, follow instructions in the plan's drug policy documents.

Prior Authorization

Authorization requirements for specific services

Some services require prior authorization with a service-specific phone or fax workflow. Examples below consolidate contact instructions from the plan:

Radiology (advanced outpatient CT/MRI/MRA, nuclear medicine and nuclear cardiology): Use the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054 for telephonic requests or questions.
Proton beam and other radiation therapy: Prior authorization required — submit via the Provider Portal or call 866-889-8054.
Home health services (outpatient/home setting, including PDN): Prior authorization required for outpatient settings — submit via the Provider Portal.
Enteral nutrition / home nutritional therapy and associated HCPCS (e.g., B40xx, B41xx, B41xx series): Prior authorization required — submit via the Provider Portal.
Transplants and CAR T-cell therapies: Call the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or the member ID card notification number.
Ventricular Assist Devices (VAD): Call the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.

Prior Authorization

Enteral services codes requiring prior authorization

Enteral services delivered in the home (enteral formulas and supplies billed under HCPCS B40xx, B41xx, B41xx series such as B4034–B4036, B4100–B4161, B9002, B9998) require prior authorization. Submit requests via the Provider Portal Prior Authorization and Notification tool.

Examples of enteral HCPCS codes requiring prior authorization: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160, B4161, B9002, B9998

Prior Authorization

Radiology prior authorization process

For radiology prior authorization (advanced outpatient imaging and PET scans), submit requests via the Provider Portal Prior Authorization and Notification tool or call 866-889-8054. PET scan codes that require prior authorization include CPT/HCPCS such as 78608, 78609, 78811–78816 and related A9xxx codes.

PET scan CPT/HCPCS examples requiring prior authorization: 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, A9515, A9526, A9552, A9580, A9587

Prior Authorization

Transplant/CAR T prior authorization process

For transplant and CAR T prior authorization and case management, call UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number printed on the back of the member's health plan ID card. Notification is required for all transplant and CAR T-cell therapy services.

Prior Authorization

VAD prior authorization and coverage note

Ventricular assist devices (VAD) require prior authorization. Note: VAD device and supplies are not covered by some benefit designs — confirm coverage before authorization. To initiate authorization, call the notification number on the back of the member's health plan ID card and fax the nurse-provided form to the Optum VAD Case Management Team at 855-282-8929.

Source noteApplies only to the DME codes specifically listed with a retail purchase or cumulative rental cost condition

Prior authorization / pre-determination

TermPrior authorization / pre-determination

PracticePre-determination is recommended for new-to-market drugs per the Review at Launch policy; authorization submitted via Provider Portal or specified phone numbers

Special codesUnclassified/temporary codes (C9399, J3490, J3590) require authorization only for specified drugs; see policy for details

Home health services (PDN)

Services coveredHome health services, including extended nursing services (PDN)

Authorization requirementPrior authorization required only in outpatient settings, including the member's home

Example codesG0299, T1000, G0300, S9123, S9124 (listed for home health/PDN)

Proton beam therapy definition

DefinitionProton beam therapy: Focused radiation therapy using beams of protons (tiny positively charged particles)

Authorization requirementPrior authorization required for proton beam therapy

Example CPT codes77520, 77522, 77523 (listed codes requiring authorization)

Advanced outpatient imaging

ScopeAdvanced outpatient imaging includes certain CT, MRI, MRA, nuclear medicine and nuclear cardiology procedures

How to obtain authorizationSubmit requests online using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com) or call 866-889-8054

Requester noteSee portal or call for specific CPT codes that require prior authorization

Ventricular assist device (VAD)

DefinitionVentricular assist device (VAD): A mechanical pump that takes over the function of the damaged heart ventricle and restores normal blood flow

Authorization stepsCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929

Coverage noteVAD device and supplies are not covered (per policy)