CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for UnitedHealthcare Connected TX (Medicare-Medicaid Plan)

List of services, codes, and instructions describing when prior authorization is required for providers participating with UnitedHealthcare Connected TX (Medicare‑Medicaid Plan); applies to inpatient and outpatient services for the plan effective July 1, 2024.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare Connected TX (Medicare-Medicaid Plan)

Policy CodePolicy N/A

Change TypeMinor/technical (no material coverage changes)

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionRequest prior authorization via the UnitedHealthcare Provider Portal, phone 877-842-3210, or fax 877-940-1972.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-07-01policy effective date

online/phone/faxsubmission methods

888-887-9003behavioral health referral

$1,000orthotics/prosthetics threshold

200+codes listed (approx)

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naviHealthpost-acute portal

Prior Authorization Coverage Criteria

inv-01: Examples of coverage criteria

Selected examples of services and coding notes requiring prior authorization include:

ALL of the following

Breast reconstruction (non-mastectomy) CPT/HCPCS codes (e.g., 19316-19325, 19355, 19318, L8600) — prior authorization is NOT required when Breast Reconstruction DX codes are present; prior authorization required for other diagnoses.
Prior Authorization Effective Date = Jan. 1, 2015.
Cardiology / Cardiovascular: Cardiology and cardiovascular procedures (examples: diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes; codes include 0571T, 33270, 0614T, 37230-37231, 93580, 33285) — prior authorization required for outpatient/office-based procedures and for members age 18+ where indicated.
Submit via UnitedHealthcare Provider Portal or call 866-889-8054; effective dates vary (examples: Oct. 1, 2016; Feb. 1, 2023; April 1, 2022).
Cochlear & inner ear implants: Cochlear implant and inner ear device codes (e.g., 69729, 69730, 69710-69711, 69930, 92601-92604, L8614, L8619) — prior authorization required; some codes show effective dates (e.g., Jan. 1, 2023).
Durable medical equipment (DME) & supplies: Extensive DME and supply HCPCS codes (examples: E0466, E2310, E0670-E0693, K0007, L3999, L5999) — many entries require prior authorization; some DME require PA regardless of billed amount and others are subject to cost thresholds.
DME Prior Authorization Effective Date entries appear (e.g., Jan. 1, 2015).
Injectable medications: Selected injectable medications and J-codes (examples: J1304 Qalsody, J9333 Rystiggo, J1576 Panzyga, J1411/J1747 Hemgenix/Spevigo, J2350 Ocrevus) — prior authorization required as listed with varying effective dates.
See listed J‑codes for specific effective dates (examples: July 1, 2023; April 1, 2023; Aug 1, 2022).
Enteral services / in-home nutrition: Enteral services (B4100-B4104, B4103) — prior authorization required for listed enteral/in-home nutritional therapy codes; some entries show Prior Authorization Effective Date = Jan. 1, 2015.
Psychological testing and advanced imaging: Psychological testing (e.g., 96116, 96121, 96130-96132) and advanced outpatient imaging codes (e.g., 78430 series, 78831, 78012-78016) — PA/notification requirements apply; notifications/submissions via UHCprovider.com Provider Portal or by phone (866-889-8054) and some PA exceptions/dates apply (e.g., psychological testing PA change Oct. 1, 2019; imaging dates Jan. 1, 2021 and March 1, 2022).
Providers ordering advanced outpatient imaging responsible for providing notification prior to scheduling.
Spinal and cranial surgeries: Numerous spinal and cranial surgery CPT codes (examples: 22510-22513, 22526, 22533-22534, 22845-22862, 63001, 63081) — prior authorization required as indicated in the code listings; some codes include explicit effective dates (e.g., 20931 July 1, 2021; 0098T Jan. 1, 2015).
Transplant, CAR T, VNS, VAD and device implantation: Transplant and CAR T services, neurostimulator/VNS implantation, and ventricular assist device (VAD) procedures require prior authorization and specific contact routing (e.g., Community and State Transplant Case Management at 888-936-7246; Optum VAD Case Management fax 855-282-8929).
Some transplant/CAR T entries show effective dates (e.g., Jan. 1, 2019; July 1, 2024) and device implantation codes show dates such as Jan. 1, 2015 and Jul. 1, 2021.

inv-02: Code-level prior authorization requirements (partial)

Codes listed in this section require submission of prior authorization information; multiple entries include prior authorization effective dates (some blank) and pointers to additional information/how to obtain prior authorization.

ALL of the following

DME codes (bulk list): Durable Medical Equipment HCPCS codes listed (examples: E0670-E0693, E0745, E0764, E0986, E1003-E1011, E1232-E1238, E1399, E1801-E1815, E1825, E1840, E2312, E2325-E2330, E2402, E2502-E2512, K0007, K0730, L3999, L5999) — prior authorization submission required; Prior Authorization Effective Date often blank or Jan. 1, 2015 for some entries.
See DME code listings for additional fields.
Enteral services codes: Enteral services (B4100-B4104, B4103) — listed with Prior Authorization Effective Date = Jan. 1, 2015 for some entries; PA submission required.
Experimental / temporary CPT codes: Category III/temporary CPT codes and experimental/investigational entries (examples: 0054T, 0055T, 0100T-0110T, A4226, 22867) — PA required with assorted effective dates (May 1, 2020; March 1, 2016; Jan. 1, 2015).

inv-03: Partial PA criteria listing — injectable medications and procedure examples with effective dates

Partial listings indicate which codes/subcategories are subject to prior authorization and note some effective dates; injectable medications and experimental/investigational items are included.

ALL of the following

Enteral services / in-home nutrition: Codes B4100-B4104 (enteral services) — Prior Authorization Effective Date = Jan. 1, 2015 for listed entries.
Experimental & investigational codes: Experimental & investigational entries and temporary CPT codes (e.g., A4226, 0054T-0055T, 0100T-0110T, 22867, 33477) — PA required with effective dates shown for some items (e.g., May 1, 2020; March 1, 2016; Jan. 1, 2015).
Injectable medications (partial): Selected injectable medication listings include brand names with J-codes (examples: Qalsody J1304; Rystiggo J9333; Panzyga J1576; Hemgenix J1411; Spevigo J1747) — PA required; listing contains individual effective dates where provided.

inv-04: Prior authorization criteria (partial list) — submission methods and exceptions noted

Prior authorization or notification is required for the services and codes listed below, with specified submission methods and exceptions.

ALL of the following

Post-acute inpatient services: Prior authorization and notification of admission date required for post-acute inpatient services (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, LTACHs, skilled nursing facilities).
Submit via naviHealth Continued Care Program — Phone: 855-851-1127; Fax: 844-244-9482 (see chunk 60).
Therapy re-evaluations: Prior authorization required for all listed therapy re-evaluations and other therapy codes; initial evaluations do not require PA; nursing facilities are exempt from PA for certain therapy codes.
Submit using Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (see chunk 67).
Orthotics / prosthetics cost threshold: Prior authorization required for orthotics/prosthetics codes when retail purchase or cumulative rental cost exceeds $1,000.

inv-05: Prior authorization / notification criteria (excerpt)

Selected coverage/authorization notes present in this section:

ALL of the following

Psychological testing codes (e.g., 96116, 96121, 96130-96132) — prior authorization will not be required for certain dates of service beginning Oct. 1, 2019 for some services; other psychological testing entries show varied PA notes.
Psychological Testing Prior Authorization Effective Date = Oct. 1, 2019 (see chunk 80).
Advanced outpatient imaging notification: Providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling; specific imaging codes (e.g., 78430 series, 78831, 78012-78016, 78070, 78072, 78099, 78199, 78227, 78399, 78459, 78582, 78608, 78799, 78800-78803, 78812-78816) are listed among entries requiring PA or notification.
Submission via UHCprovider.com Provider Portal is referenced (chunks 82-83).
Portal and phone submission: Providers should submit PA/notifications via the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool or call the designated phone numbers (examples: 866-889-8054 for cardiology portal instructions; 866-889-8054 referenced for imaging).

inv-06: Prior authorization presence for listed procedures

Procedures listed require prior authorization or notification as indicated by the 'Prior Authorization Effective Date' and related fields.

ALL of the following

If a procedure entry includes a 'Prior Authorization Effective Date', then prior authorization is required for that procedure (examples: rhinoplasty 30400/30410 Prior Authorization Effective Date = Jan. 1, 2015; sleep apnea 41512 Prior Authorization Effective Date = Jan. 1, 2015).
See chunks 98 and 99.
When 'Additional Information/How to Obtain Prior Authorization' is blank for a listed procedure, providers should consult the UnitedHealthcare Provider Portal or contact the plan for submission instructions.
See chunk 90 regarding form fields and how to obtain prior authorization guidance.
Some codes show historical effective dates (e.g., Jan. 1, 2015 for certain ENT and sleep apnea entries; July 1, 2021 for select spinal codes such as 20931), indicating the PA requirement has applied since those dates.
See chunks 99 and 100 for examples.

inv-07: Listed-code prior authorization requirements

Codes and associated prior authorization effective dates / contact instructions where provided:

ALL of the following

Spinal and cranial surgery codes: Multiple spinal surgery CPT codes enumerated (examples: 22845-22862, 63001, 63003, 63005, 63011, 63012, 63015) — prior authorization required as per code listings; some entries include Prior Authorization Effective Dates.
See chunk 118.
Neurostimulator / device implantation: Neurostimulator implantation and related device codes (E0747, E0748, L8682, L8683) — prior authorization required; examples show Prior Authorization Effective Date = Jan. 1, 2015 and implantation device effective dates such as July 1, 2021.
See chunk 122.
Transplant / CAR T codes: Transplant and CAR T related codes (examples: 0538T, 0540T, Q2041, 32850-32856, 33930-33944) — prior authorization required with some Prior Authorization Effective Dates noted and instruction to contact Community and State Transplant Case Management team at 888-936-7246 or the notification number on the member's ID card.

inv-08: Submission and contact requirements (partial)

Providers must obtain prior authorization for the listed procedures and devices using the specified contact routes.

ALL of the following

Transplant / CAR T submission: Contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's health plan ID card for transplant/CAR T prior authorization and coordination.
See chunk 126 for contact instructions.
VAD prior authorization routing: For Ventricular Assist Device (VAD) services, call the notification number on the back of the member's health plan ID card and then fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.
See chunk 132 for VAD instructions.
Post-acute inpatient submission route: Submit prior authorization requests for post-acute inpatient services through naviHealth (Continued Care Program).

Code Lists and Coding Notes

Durable Medical Equipment (HCPCS) - AdditionalHCPCS

E0670	Splint, shoulder immobilizer
E0693	Other DME
E0745	Traction equipment
E0764	Hip/knee orthosis
E0986	Breast prosthesis
E1003	Enteral feeding supply
E1005	Enteral feeding supply
E1007	Enteral feeding supply
E1009	Enteral feeding supply
E1011	Enteral feeding supply

1–10 of 47

1/5

Procedure CPT / Temporary CodesCPTExperimental

0102T	Unlisted procedure, experimental series
0103T
0104T
0105T
0106T
0107T
0108T
0109T
0110T
0054T

1–10 of 11

1/2

How Providers Submit Prior Authorization Requests

Prior Authorization

Submitting prior authorization requests

You can request prior authorization in one of the following ways: - Online: Use the UnitedHealthcare Provider Portal. Go to UHCprovider.com and click Sign In in the top-right corner. Then, select Prior Authorization and Notification on your provider portal dashboard. - Phone: 877-842-3210 - Fax: 877-940-1972. The fax form is available at UHCprovider.com/TXcommunityplan > Prior Authorization and Notification Resources > Prior Authorization Forms Prior authorization is not required for emergency or urgent care. Out-of-network requests must be made by an in-network provider for all procedures and services, excluding emergent or urgent care. Durable Medical Equipment (DME) and related supplies (including many orthotics/prosthetics and enteral/feeding supplies) require prior authorization for listed codes. Prior authorization is required regardless of billed amount for some prosthetics and DME codes; orthotics require prior authorization when retail purchase or cumulative rental cost exceeds $1,000. Incontinence supplies require prior authorization through the service coordinator when not provided by Tenderheart Health Outcomes. To obtain incontinence supplies from Tenderheart Health Outcomes, call 866-295-2319. To obtain incontinence supplies from a provider other than Tenderheart Health Outcomes, call the service coordinator at 800-349-0550.

Submit prior authorization online via the Provider Portal > Prior Authorization and Notification
Phone: 877-842-3210
Fax: 877-940-1972 (forms at UHCprovider.com/TXcommunityplan)
Incontinence supplies: Tenderheart Health Outcomes 866-295-2319; service coordinator 800-349-0550

Definitions and Key Terms

Prior authorization — definition and purpose

DefinitionPrior authorization: approvals requested from UnitedHealthcare before performing non-emergent services to determine coverage.

PurposeTo confirm medical necessity and coverage before services are rendered; not required for emergency or urgent care.

Submission methodsRequests may be submitted online via the UnitedHealthcare Provider Portal, by phone (877-842-3210), or by fax (877-940-1972).

Service coordinator — contact and coordination

RoleService coordinator: entity to contact for certain supplies (for example, incontinence supplies) and to coordinate authorizations.

Contact examplesTo obtain incontinence supplies from Tenderheart Health Outcomes call 866-295-2319; to obtain from other providers call the service coordinator at 800-349-0550.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare Connected TX (Medicare-Medicaid Plan)

Policy CodePolicy N/A

Change TypeMinor/technical (no material coverage changes)

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionRequest prior authorization via the UnitedHealthcare Provider Portal, phone 877-842-3210, or fax 877-940-1972.

SourceLink

On This Page

Injectable medication J-codes: Selected injectable medication HCPCS/J-codes (e.g., J1304, J9333, J1576, J1411, J1747, J2350, J3590) — require PA submission; effective dates provided where noted (examples: April 1, 2024; July 1, 2023; April 1, 2023).

Unclassified / temporary injectables: Temporary/unclassified injectable codes (J3590, J3490, J3490-series) — appear in listing and are subject to PA where indicated (example: Adzynma C9167/J3490 Prior Authorization Effective Date = April 1, 2024).

Orthotics example L3020 shows Prior Authorization Effective Date = Jan. 1, 2015 and cost threshold guidance (see chunk 66).

Injectable medications and other codes listed: Multiple injectable medication HCPCS codes and various CPT/HCPCS procedure codes are listed with individual effective dates where specified (examples include J1304, J9333, J1576, J2350 and numerous L‑codes and CPT codes).

See J‑code listings and code groups for details (chunks 55, 59, 33).

See chunks 82-83 for portal navigation and phone instructions.

Listed L-codes and CPT codes: Multiple L‑codes and CPT/radiology codes are listed as subject to PA/notification; exact requirements per code are specified in the detailed code entries of the document.

Examples of listed codes appear across chunks 72, 78, 80, 82, 83.

See chunk 126 and 129.

Phone: 855-851-1127; Fax: 844-244-9482 (see chunk 60).

Therapy PA submission: Submit therapy re-evaluation prior authorization online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal; initial evaluations do not require PA and nursing facilities are exempt for certain therapy codes.

See chunk 67 for portal-based submission guidance.

Note

Behavioral health prior authorization routing

Behavioral health services may be managed through a designated behavioral health network. When referring for mental health and substance use services, call 888-887-9003. Behavioral health referrals should follow the same submission pathways (portal, phone, fax) unless otherwise directed by the behavioral health network.

Behavioral health referrals phone: 888-887-9003
Submit BH prior authorizations via Provider Portal or phone per network instructions

Documentation Required

Prosthetics/DME prior authorization notes

Prosthetics and orthotics: Prior authorization is required for prosthetic codes listed with a retail purchase or cumulative rental cost greater than $1,000. Prosthetics are not classified as DME for some items; prior authorization may be required regardless of billed amount for specified prosthetic codes. Orthotics prior authorization effective date for L3020 (example) is Jan. 1, 2015.

Prior authorization required for prosthetic codes when retail/cumulative rental cost > $1,000
Some prosthetic codes require PA regardless of billed amount
Orthotics example: L3020 — Prior Authorization Effective Date: Jan. 1, 2015

Prior Authorization

Submitting prior authorization requests (code list)

Durable Medical Equipment (DME) — selected HCPCS examples requiring prior authorization: E0466, E2310, E1230, E2311, E2321, K0800, K0801, K0802, K0806, K0808, E0670, E0693, E0745, E0764, E0986, E1003, E1005, E1007, E1009, E1011, E1030, E1232, E1234, E1236, E1238, E1399, E1801, E1805, E1811, E1815, E1825, E1840, E2312, E2325, E2328, E2330, E2402, E2502, E2506, E2510, E2512, K0007, K0730, L3999, L5999, E0638, E0692, E0694, E0762, E0784, E0984, E1002, E1004, E1006, E1008, E1010, E1018, E1161, E1233, E1235, E1237, E1800, E1802, E1810, E1818, E1830, E2227, E2322, E2327, E2329, E2376, E2500, E2504, E2508. Prior Authorization effective dates vary by code group (many list Jan. 1, 2015 or later).

DME examples (partial list): E0466, E2310, E1230, E2311, E2321, K0800, K0801, K0802
Expanded DME code examples (partial): E0670, E0693, E0745, E0764, E0986, E1003, E1005, E1007, E1009, E1011, E1030, E1232, E1234, E1236, E1238, E1399
Many DME and enteral service codes have Prior Authorization Effective Date = Jan. 1, 2015

Note

Enteral services and Experimental & Investigational codes

Enteral services (in-home nutritional therapy) require prior authorization for home enteral nutritional supplies and related HCPCS codes. Examples include B4100, B4103, B4104; Prior Authorization Effective Date: Jan. 1, 2015 for many enteral codes. Experimental, investigational, and linked services are listed separately and have specific effective dates (examples: A4226; some codes have effective dates May 1, 2020 or Jan. 1, 2017).

Enteral service examples: B4100, B4103, B4104 — Prior Authorization Effective Date often Jan. 1, 2015
Experimental & Investigational examples include A4226 and certain CPT/T codes with varied effective dates (see code-specific listings)

Prior Authorization

Injectable medications requiring prior authorization (partial)

Injectable medications: Selected specialty and high-cost injectables require prior authorization. Examples from the partial list include Qalsody® (J1304), Rystiggo® (J9333), Hemgenix® (J1411), Spevigo® (J1747), Cutaquig® (J1551), Apretude™ (J0739), Leqvio® (J1306), Entyvio™ (J3380), Panzyga® (J1576). Effective dates vary by product (examples: July 1, 2023; April 1, 2023; Aug 1, 2022; July 1, 2022).

Injectable examples (partial): J1304 (Qalsody®), J9333 (Rystiggo®), J1411 (Hemgenix®), J1747 (Spevigo®), J1551 (Cutaquig®), J0739 (Apretude™)
PA effective dates vary by drug (see drug-specific listings)

Note

Therapy prior authorization submission

Therapies: Prior authorization is required for re-evaluations and many therapy codes listed (PT/OT/Speech). Initial evaluations generally do not require prior authorization; re-evaluations and ongoing therapy services do. Submit therapy prior authorization online using the Prior Authorization and Notification tool on the Provider Portal.

Therapy PA submission: Provider Portal > Prior Authorization and Notification
Prior authorization required for re-evaluations and listed therapy codes; initial evaluations typically do not require PA

Prior Authorization

Post-acute inpatient prior authorization submission

Post-acute inpatient services (acute hospitals, inpatient rehab, critical access hospitals, LTACHs, skilled nursing facilities): Prior authorization and notification of admission date is required. Submit prior authorization requests through naviHealth as part of the Continued Care program. Phone: 855-851-1127; Fax: 844-244-9482.

naviHealth Continued Care program phone: 855-851-1127
naviHealth fax: 844-244-9482
Required for acute care hospitals, inpatient rehab, critical access, LTACH, skilled nursing facilities

Note

Transplant/CAR T prior authorization contact

Transplant and CAR T services: Contact the Community and State Transplant Case Management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card for prior authorization and case management instructions.

Transplant hotline: 888-936-7246
See member ID card notification number for additional instructions

Prior Authorization

Neurostimulator/device prior authorization

For device implants and neurostimulators (including VNS) prior authorization is required for device and implantation procedure codes. Examples include neurostimulator device and implantation codes L8682/L8683 (implantation of device that sends electrical impulses) and VNS codes 61888, 64569, L8681, L8689. Prior Authorization Effective Dates vary (examples: Jan. 1, 2015; July 1, 2021).

Neurostimulator/VNS example codes: 61888, 64569, L8681, L8682, L8683, L8689
PA effective dates vary by code (see specific listings)

When usedService coordinator involvement is required when supplies are not provided by Tenderheart Health Outcomes and prior authorization is necessary.

Durable Medical Equipment (DME) — definition and coding note

DefinitionDurable Medical Equipment (DME): medical equipment items identified by HCPCS codes in the DME sections that may require prior authorization.

Coding noteMany DME HCPCS codes are listed (examples: E0670–E0693, E0745, E0764, L3999, L5999) and entries reference diagnosis code and prior authorization effective date fields.

Prior authorizationSome DME items require prior authorization regardless of billed amount or when cost/rental thresholds are exceeded.

Enteral Services — definition and examples

DefinitionEnteral Services: in-home nutritional therapy delivered enterally (examples include HCPCS codes B4100–B4104 and B4103).

ExamplesCodes listed for enteral/in-home nutritional therapy include B4100, B4103, B4104 with Prior Authorization Effective Date shown (Jan. 1, 2015 for some entries).

SettingCovers in-home nutritional therapy either enteral or via gastrostomy tube as specified in the code listings.

Experimental & Investigational — definition and examples

DefinitionExperimental & Investigational: procedures or services identified as investigational in the code listings and subject to prior authorization review.

ExamplesCategory III/temporary CPT codes and other listed codes flagged as investigational include entries with effective dates (examples: 0055T, 0102T–0110T; A4226; effective dates such as May 1, 2020 or March 1, 2016 shown).

Review notePrior authorization entries for investigational items often include an effective date indicating when the investigational PA requirement began.

Gender Dysphoria Treatment — prior authorization note

ContextGender dysphoria treatment PA note: prior authorization is required for the listed gender dysphoria treatment codes when submitted with the applicable diagnosis codes.

ExamplesCodes listed include 55970, 55980 and multiple reconstructive procedure codes; entries show a Prior Authorization Effective Date (e.g., Jan. 1, 2017) for many items.

How to applyPrior authorization is required 'for these codes with any DX' or 'only required with these DX codes' as specified per code entry.

Enteral / In‑home nutritional therapy — definition and example codes

DefinitionEnteral / In‑home nutritional therapy: nutrition provided enterally or via gastrostomy tube for home use, coded to B4100–B4104.

Example codesB4100, B4103, B4104 are listed with a Prior Authorization Effective Date of Jan. 1, 2015 for some entries.

ApplicationAuthorization entries direct providers to the code listings for prior authorization requirements and any Additional Information fields.

Continued Care Program (naviHealth) — definition

ProgramContinued Care Program (naviHealth): the program used for post‑acute inpatient prior authorization and care coordination.

SubmissionSubmit prior authorization requests through naviHealth for post‑acute inpatient services; Phone: 855-851-1127, Fax: 844-244-9482.

Covered settingsApplies to acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals, and skilled nursing facilities.

Prior Authorization and Notification tool — portal definition

ToolPrior Authorization and Notification tool: the online function on the UnitedHealthcare Provider Portal used to submit prior authorization requests (notably for therapy re‑evaluations).

How to accessAccess via UHCprovider.com > Sign In > Prior Authorization and Notification on the provider portal dashboard.

Usage noteTherapy re‑evaluation prior authorizations should be submitted using this tool; initial evaluations do not require PA and some nursing facility items are exempt.

Psychological Testing — code examples and prior authorization note

ExamplesPsychological testing codes listed include 96116, 96121, 96130–96132 and 96131.

PA notePrior authorization for psychological testing is discussed; some psychological testing PA will not be required beginning Oct. 1, 2019 for specified services.

SubmissionProviders should use UHCprovider.com/Provider Portal or call 866-889-8054 for submission and notifications related to these services.

UHCprovider.com Provider Portal — portal submission definition

DefinitionUHCprovider.com Provider Portal: UnitedHealthcare's online portal where providers sign in to submit Prior Authorization and Notification requests.

Access stepsGo to UHCprovider.com, click Sign In (top‑right), then select Prior Authorization and Notification on the provider portal dashboard.

Alternative channelsPhone (877-842-3210) and fax (877-940-1972) are available if portal submission is not used.

Prior Authorization Effective Date — field meaning

Field meaningPrior Authorization Effective Date: the date from which the prior authorization requirement applies for the listed procedure.

Use in listingsEntries with a Prior Authorization Effective Date indicate the authorization requirement has been in effect since that date.

Provider actionIf the 'Additional Information/How to Obtain Prior Authorization' field is blank, providers should consult the portal or plan contact for submission instructions.

Additional Information / How to Obtain Prior Authorization — field meaning

Field purposeAdditional Information/How to Obtain Prior Authorization: describes how providers secure authorization or notification for the listed procedure.

Common entriesMay direct providers to use UHCprovider.com Provider Portal, call specific phone numbers, or reference program contacts such as naviHealth or transplant case management.

If blankWhen this field is blank in the code listing, providers should use the portal or contact the plan for instructions.

Neurostimulator — definition

DefinitionNeurostimulator: implantation of a device that sends electrical impulses (device/stimulator codes listed in the policy).

Example codesExamples include E0747, L8682, L8683 and other stimulator/implantation device codes listed with Prior Authorization Effective Dates (e.g., Jan. 1, 2015; July 1, 2021).

Prior authorizationNeurostimulator implantation codes are listed with prior authorization requirements and effective dates in the code listings.

CAR T‑Cell Therapy — definition and examples

DefinitionCAR T‑Cell Therapy: cellular immunotherapy products listed under transplant/CAR T entries that require prior authorization via the transplant/CAR T process.

ExamplesProduct examples named include Abecma (idecabtagene vicleucel), Breyanzi (lisocabtagene...), Kymriah (tisagenlecleucel), Tecartus, Yescarta and Q2055/Q2054/Q2053 codes referenced in the listings.

ContactPrior authorization for CAR T‑Cell therapies requires contacting UnitedHealthcare Community and State Transplant Case Management as indicated in the listings.

Ventricular Assist Device (VAD) — definition

DefinitionVentricular Assist Device (VAD): a mechanical pump that takes over the function of a damaged ventricle and restores normal blood flow.

Example codesVAD-related CPT/HCPCS codes listed include 33927, 33929, 33975, 33979, 33982 (and others in the series).

Prior authorizationVAD implantation and related codes are listed in the policy and require prior authorization and specific contact routing (Optum VAD Case Management referenced elsewhere).

Vagus Nerve Stimulation (VNS) — definition

DefinitionVagus Nerve Stimulation (VNS): implantation of a device that sends electrical impulses into one of the vagus nerves.

Example codesProcedure codes include 61888 and 64569; device HCPCS codes include L8681 and L8689. Prior Authorization Effective Date examples include Jan. 1, 2015 and July 1, 2021 in some entries.

NotesVNS implantation entries direct providers to the code listings for prior authorization requirements and any Additional Information fields.