Prior authorization is required for the following categories of services. Providers should submit PA requests via the UnitedHealthcare/Optum portals or call the phone numbers listed for the specific program when noted.
Transplants (including CAR T-cell therapy) — Prior authorization required. For transplant and CAR T‑cell therapy services (e.g., Kymriah, Yescarta) call Optum Transplant Case Management at 888-936-7246 or use the number on the back of the member's ID card.
Radiation therapy — Prior authorization required for outpatient radiation therapy, including Image-Guided Radiation Therapy (IGRT) (77014, 77387, G6001, G6002) and Intensity-Modulated Radiation Therapy (IMRT). Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.
Advanced outpatient imaging (Radiology) — Prior authorization required for certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures. Ordering providers must notify prior to scheduling; use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.
Cardiology procedures — Prior authorization required for participating physicians for outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiography. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-889-8054.
Site of Service rules — Prior authorization required when requesting services in an outpatient hospital setting for listed procedures; prior authorization may not be required if performed at a participating ambulatory surgery center (ASC).
Chemotherapy (injectable) — Prior authorization required for outpatient injectable chemotherapy drugs (J9000-J9999 and related J/Q/misc HCPCS codes), including IV, intravesical and intrathecal administration for a cancer diagnosis. Submit via the Prior Authorization and Notification tool or call 888-397-8129.
Cancer supportive care (colony-stimulating factors and bone-modifying agents) — Prior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Specific injectable CSF and related codes (e.g., J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require PA; some codes require PA regardless of diagnosis (see injectable medications section). Submit requests online via the UnitedHealthcare Provider Portal or call 888-397-8129.
Injectable medications (selected biologics, orphan and specialty injectables) — Prior authorization required for an extensive list of injectable medications (examples include J0801 Acthar Gel, J3262 Actemra, J0791 Adakveo, J1426 Amondys-45, Q5121 Avsola, J0490 Benlysta, J0179 Beovu, J0597 Berinert and many others). Providers must follow PA submission instructions listed in the Provider Portal.
Intravenous immunoglobulin (IVIG) — Prior authorization required for IVIG products and related billing codes; submit requests per portal instructions.
Genetic and molecular testing (including BRCA testing) — Prior authorization/notification required for outpatient genetic and molecular testing. Ordering providers must indicate the laboratory and test name during the PA/notification process; BRCA testing requires notification/prior authorization before DNA sequencing is performed.
Durable Medical Equipment (DME), enteral and home nutritional services — Prior authorization required for listed DME/orthotics/prosthetics and enteral/home nutrition codes. Certain DME codes require PA only when billed with retail; submit via Provider Portal or call 888-397-8129.
Home health care and private duty nursing — Prior authorization required for home health services (e.g., G0156, G0162) and private duty nursing (T1002, T1003).
Sleep studies and sleep apnea procedures — Prior authorization required for sleep studies (95805, 95807, 95808, 95810) and specified surgical procedures for obstructive sleep apnea, including maxillomandibular procedures.
Joint replacement and major orthopedic procedures — Prior authorization required for joint replacement (total hip and knee) and selected spinal and orthopedic surgeries; providers should submit PA requests per portal guidance.
Spinal surgery and other major procedures — Prior authorization required for listed spinal surgery CPT codes and additional major surgical services.
Vein procedures — Prior authorization required for removal/ablation of saphenous veins and named branches for venous disease/varicose veins (e.g., 36473, 36475, 36478, 37700).
Ventricular assist devices (VAD) — Prior authorization required. Call the notification number on the back of the member's ID card and follow Optum VAD Case Management instructions (fax forms to 855-282-8929 when directed).
Stimulators and neurostimulation devices (including bone growth stimulators) — Prior authorization required for implantation of devices that send electrical impulses (e.g., E0749, E0760) and related neurostimulator services.
Potentially unproven or investigational services — Prior authorization required for services considered experimental or investigational and for linked services; specific CPT/HCPCS codes are identified in the Provider Portal.
Hearing aid services and cochlear/other auditory implants — Prior authorization required for hearing aid services and cochlear implants; see listed V-codes and CPT codes (e.g., 69710, 69711, 69714, 69930 and V51xx series) and submit via the Provider Portal or call 888-397-8129.
Biomarker and specialty laboratory testing — Prior authorization required for specified biomarker and advanced laboratory tests; listed CPT/HCPCS codes must be registered with the Genetic and Molecular Testing Prior Authorization program for payment.
Other categories requiring prior authorization (partial list) — Abortion services (carved out by the state; call the number on the back of member ID card for PA), acupuncture, bariatric surgery and obesity-related services, breast reconstruction following mastectomy, orthognathic surgery, enteral services, outpatient therapy for adults over specified ages, pain injections/management when identified, and other services indicated in the Provider Portal.