CurrentColorado Rocky Mountain Health Plans | UnitedHealthcare Individual & Family (ACA Marketplace) list (applies to participating plans in listed states)Policy N/A

Prior authorization requirements for UnitedHealthcare Individual Exchange plans

List of services and CPT/HCPCS/diagnosis codes that require prior authorization for participating UnitedHealthcare Individual & Family (ACA Marketplace) plans and instructions for submitting requests; applies to providers and members in specified states.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (UHCprovider.com) or call the listed phone number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+states covered (partial)

11/01/2024effective

Dozens+codes listed

portal + phonesubmission methods

Center of Excellence

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

Partial coverage criteria and notes

Partial coverage criteria and notes: This group lists services or codes that are subject to prior authorization only in specific circumstances, states, or sites of service; and notes exclusions. Providers must reference member-specific benefit plans and state exceptions when requesting authorization.

All: Prior authorization required unless otherwise noted. Review member-specific benefit plan; site-of-service review may apply to certain codes. Prior authorization is not required for emergency or urgent care.

State exclusions: Some codes or categories are excluded from prior authorization requirements in certain states (for example: New Mexico, South Carolina, Wisconsin, Illinois, Maryland; specific codes carry * or ** denoting state exceptions). Check code-level notes for exact state exclusions.

Site of service (SOS) review: SOS review may apply for outpatient hospital services and other codes; Texas and Wisconsin often require prior authorization for listed codes but are excluded from SOS review in some categories. When SOS review applies, authorization may differ if services are performed in an ASC versus outpatient hospital.

Center of Excellence (COE) requirement: Bariatric surgery and related services require COE designation for coverage when noted.

Cochlear implants: Prior authorization required; codes include 69710, 69714, 69717, 69930 and related L-series device codes (L8615–L8628).

Injectable/biologic drugs: Many J-, C-, and Q-codes require prior authorization or predetermination. Unclassified codes (J3490, J3590, C9151, C9167, C9168, C9172) require notification/prior authorization only for specified products (e.g., Beqvez, Fylnetra, Nulibry, Revcovi, Rivfloza).

Chemotherapy and cancer supportive care: Prior authorization required for many chemotherapy J-codes and supportive agents; colony-stimulating factors and bone-modifying agents require authorization in outpatient settings (e.g., J0897, J1442, J2506, J2820, Q5101, Q5110, Q5111, Q5120, Q5122).

Continuous glucose monitoring (CGM): Prior authorization required for members with type 2 diabetes and gestational diabetes diagnoses. Prior authorization not required for type 1 diabetes. Relevant HCPCS include A4226, A4238, A4239, A9276–A9278, E0787, E2102.

Cosmetic vs reconstructive procedures: Procedures that are purely cosmetic (no significant improvement or restoration of physiologic function) may be excluded or require prior authorization when potentially cosmetic. Reconstructive procedures to restore function typically require prior authorization; check codes and diagnosis associations.

Procedures with site-of-service exclusions: Certain office-based procedures may be excluded from SOS review in Texas and Wisconsin, but prior authorization may still be required depending on setting. Providers ordering advanced outpatient imaging must notify/request authorization before scheduling.

Genetic and molecular testing: Prior authorization required for many genetic tests (including BRCA and other molecular panels); check code-level listings (e.g., 81433 and related CPT/HCPCS mappings).

Fertility services / infertility: Diagnostic and treatment services related to inability to achieve pregnancy require prior authorization; many associated CPT codes (e.g., 55870, 58321–58323, 58345, 58752, 58970, 58974, 58976, 76948, 89250–89251) and diagnosis exclusions vary by state.

Orthognathic, orthotics & prosthetics, neurostimulators, pain management, proton beam therapy, foot surgery, FESS, and other specialty categories: Prior authorization required; some codes have state-specific exclusions or SOS review. Examples: orthognathic (21010, 21050, 21121–21199 series), orthotics/prosthetics (L0112, L0220, L0452, L0482, L0484, L0486, L0622, etc.), neurostimulators (43647, 61863, 61885), proton beam CPT 77520–77523.

Operational requirement: Submit prior authorization requests via the UnitedHealthcare Provider Portal (UHCprovider.com) using the Prior Authorization and Notification tool or call the provider support line where indicated. Include clinical documentation, diagnosis codes, and site-of-service details.

Claim processing note: Members in these benefit plans generally have no non-emergent out-of-network coverage and no coverage outside the service area; verify network participation prior to scheduling.

Documentation and clinical trials: When services are part of a clinical trial, clinical-trial specific codes (e.g., G0293–G0294, G2000) and documentation may be required; see clinical trials section for details.

CPT / HCPCS / ICD-10 Code Lists

Chemotherapy HCPCS/J-codes requiring prior authorization (selected)HCPCSCovered

J1449	Injection, daratumumab and hyaluronidase-fihj (Darzalex Faspro)
J9255	Injection, oxaliplatin
J9258	Injection, ifosfamide
J9259	Injection, melphalan
J9260	Injection, carmustine
J9261	Injection, mitomycin
J9262	Injection, bendamustine
J9263	Injection, vinorelbine
J9264	Injection, vinblastine
J9266	Injection, epirubicin

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How Providers Obtain Authorization and Required Notifications

Prior Authorization

Submit requests via UHCprovider.com portal

Submit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (sign in with One Healthcare ID).

Note

Emergent/urgent care and member-specific coverage

Prior authorization is not required for emergency or urgent care; when deciding coverage reference the member-specific benefit plan document.

Prior Authorization

Center of Excellence required for bariatric coverage

Bariatric surgery coverage requires enrollment in a Center of Excellence for coverage of bariatric surgery and services.

Key Definitions and Terms

Prior authorization

DefinitionA requirement to obtain approval from UnitedHealthcare before performing certain non-emergent services; emergency and urgent care are excluded.

How to submitUse the Prior Authorization and Notification tool on UHCprovider.com (Sign in with One Healthcare ID) or call 866-889-8054 for specified workflows.

ScopeApplies to the participating Individual Exchange (UnitedHealthcare Individual & Family) plans in the states listed in the policy.

Center of Excellence

DefinitionDesignated facility requirement for coverage of bariatric surgery and related services — services must be performed at an approved Center of Excellence.

Affected servicesBariatric surgical CPT codes such as 43846, 43847, 43848, 43886, 43887, 43888 (see policy) carry the Center of Excellence requirement.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Individual Exchange plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal using the Prior Authorization and Notification tool (UHCprovider.com) or call the listed phone number.

SourceLink

On This Page

Prior Authorization

How to obtain prior authorization (portal or phone)

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

Prior Authorization

Cardiology procedures: notification/prior authorization required

Notification or prior authorization is required for many cardiology procedures and participating providers; submit via the portal or by phone.

Prior Authorization

Anti-emetics and supportive drugs require prior authorization

Anti-emetic and related supportive oncology items are listed as requiring prior authorization; prior authorization submission instructions are provided in the anti-emetics section.

Examples of listed agents and supportive drugs appear in the injectables/chemotherapy sections.

Prior Authorization

Chemotherapy drugs and related codes require prior authorization

Prior authorization is required for the chemotherapy J‑ and Q‑codes listed; inpatient chemotherapy services require prior authorization (site-of-service notes apply).

Extensive chemotherapy J‑code listing is provided in the policy (see J9247–J9376 and many others).
Site-of-service review may apply; inpatient chemotherapy requires authorization.

Documentation Required

Chemotherapy J/Q-code prior authorization list

Prior authorization is required for the listed chemotherapy J‑ and Q‑codes shown in the chemotherapy list.

Prior Authorization

Clinical trials codes require prior authorization

Clinical trial–related CPT/HCPCS codes (for example G0276, G0293, G0294, G2000, S9990, S9991) are noted; prior authorization is required.

Prior Authorization

Cochlear implants require prior authorization

Cochlear implants and auditory implant devices require prior authorization; device and procedure codes are listed (e.g., 69710, 69714, 69717, 69930, L86xx, V5273).

Prior authorization is required for cochlear implant procedures and associated HCPCS device codes.

Prior Authorization

CGM requires prior authorization for type 2 and gestational diabetes

Continuous glucose monitoring devices require prior authorization when the diagnosis is type 2 diabetes or gestational diabetes; prior authorization is not required for type 1 diabetes.

Examples of CGM HCPCS: A4226, A4238, A4239, A9276–A9278, E0787, E2102.

Prior Authorization

Cosmetic vs reconstructive — prior authorization required for listed services

Distinguish cosmetic from reconstructive procedures; prior authorization is indicated for listed cosmetic/reconstructive services and associated DME/prosthetics.

DME and prosthetics associated with reconstructive services are listed and require prior authorization (partial HCPCS list provided).

Prior Authorization

DME items on the list require prior authorization

Prior authorization is required for listed DME/HCPCS codes shown in the DME section (partial list present in the document).

Documentation Required

K‑series DME: prior authorization and state exclusions

Many K‑series DME codes require prior authorization; several of these codes include explicit state exclusions noted in the list.

Examples include K0005, K0008, K0009 and multiple K08xx codes marked with state notes.

Prior Authorization

Foot surgery codes require prior authorization (SOS may apply)

Foot surgery CPT codes listed require prior authorization; site-of-service review may apply for most states (Texas and Wisconsin are excluded from SOS review in places).

Examples include CPT 28285, 28289, 28291–28299.

Prior Authorization

Experimental/investigational services require prior authorization

Services identified as experimental or investigational in the document require prior authorization.

Prior Authorization

FESS procedures require prior authorization

Functional endoscopic sinus surgery (FESS) CPT codes (e.g., 31240, 31253–31257, 31276, 31287–31288) require prior authorization.

Prior Authorization

Gender dysphoria procedures require notification or prior authorization

Gender dysphoria treatment procedures require notification or prior authorization; some listed codes are excluded in South Carolina and Wisconsin.

Numerous CPT codes (for example 11980, 14000–14001, 15734, 19303, 54125, 54520, 57110, 58661, 58940, 64856, 64892) are identified with Notification or prior authorization.

Documentation Required

Notification or prior authorization for gender dysphoria and cosmetic/reconstructive codes

Gender dysphoria and certain cosmetic/reconstructive CPT/HCPCS codes are identified with 'Notification or prior authorization' in this section.

Prior Authorization

BRCA/genetic and molecular testing require prior authorization

BRCA genetic testing and numerous molecular/U‑codes require prior authorization or notification before testing is performed; some market/state exceptions are noted.

Examples include CPT 81162/81163 and many U‑codes (e.g., 0022U, 0216U, 0238U) listed for prior authorization.

Prior Authorization

HCPCS/V‑codes and therapy services require prior authorization

Various HCPCS/V‑codes and therapy/service codes require prior authorization; some codes have market- or state-specific exceptions and age-based notes (members 21+).

Examples include V5095, V5253, G0155 and therapy-related G‑codes listed with prior authorization requirements.

Prior Authorization

Infertility-related diagnostic and treatment services require prior authorization

Infertility diagnostic and treatment services require prior authorization for the extensive set of CPT/HCPCS codes listed in the infertility sections.

Selected example CPT codes include 54500, 58140–58146, 58660–58673, 58770 and numerous S‑codes and lab/procedure codes.

Prior Authorization

Infertility procedures (partial list) require prior authorization

Prior authorization is required for the infertility-related diagnostic and treatment CPT codes listed (partial list shown).

Prior Authorization

Additional infertility procedure codes require prior authorization

Additional CPT/HCPCS procedure and S‑codes for infertility-related services are listed and require prior authorization; some codes carry special notes or asterisks.

Documentation Required

Diagnosis codes accompanying infertility prior authorization

ICD‑10 diagnosis codes associated with infertility services (for example E23.0, N46.01, N46.021, N46.022) are listed; prior authorization applies when these diagnoses are present.

Prior Authorization

Injectable medications require prior authorization

Injectable drugs and many HCPCS J‑/C‑/A‑codes require prior authorization as indicated; an extensive injectables list appears across multiple sections.

Many specific J‑codes (J0121, J1451, J1230, J1240, etc.) are listed throughout the injectables sections.

Documentation Required

Injectable HCPCS/J‑codes (partial list)

Partial lists of HCPCS J‑codes subject to prior authorization are provided in successive segments; consult the injectables sections for full code enumeration.

Documentation Required