Prior authorization criteria (part 13) — consolidated and complete. The following services require prior authorization as indicated. When a code is listed, prior authorization is required for that service or product unless an exception is noted. Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool to submit requests, or call the number on the member's ID card (see header for portal/phone details).
For code J0897 — prior authorization is required only for non-oncology indications. See Review at Launch for New to Market Medications Policy for newly approved drugs; pre-determination is recommended for drugs on that list.
Injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis require prior authorization. This includes: chemotherapy injectable drugs (J9000–J9999), leucovorin (J0640), levoleucovorin (J0641, J0642), Lupron Depot (J1950), chemotherapy agents with a Q-code, and agents billed under miscellaneous HCPCS codes.
Cancer supportive care: prior authorization required for colony-stimulating factors and bone-modifying agents administered outpatient for a cancer diagnosis. Specific HCPCS/J-codes requiring prior authorization include (non-exhaustive list): Q5101, J1442, Q5110, Q5125, J2506, J1447, J1448, J1449, J2820, J0185, J1453, J1454, J1627, J1456, J0897 (only for non-oncology indications).
Injectable medications: a broad list of biologics, specialty injectables, and other high-cost drugs require prior authorization. Examples include (not limited to): J0225, J0256, Q5121, J0490, J0179, J0597, J0584, J1551, J3060, J1302, J1305, J0178, J1439, J9217, J3398, J1306, J0174, J2778, J1428, J1951, J1439, J1439 (Injectafer), and many other J- and Q-codes listed in the injectable medications section. Follow the portal process or call 888-397-8129 for chemotherapy/oncology drug PA.
Genetic and molecular testing performed in the outpatient setting (including BRCA and other listed molecular/procedural codes) require prior authorization. Representative CPT/HCPCS codes include 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81194, 81208, 81216, 81228, 81229, 81237, 81245, 81246, 81276, 81277, 81307, 81349, 81379, 81380, 81381, 81400–81420 series, 81425, 81431–81440, 81445, 81448, 81460, 81465, 81479, 81507, 81518–81520, 81521–81525, 81546, 81595, 81599, 87505–87507, and listed proprietary (0006M, 0007M, 0018U, 0019U, 0022U, 0023U, etc.) codes. Submit via portal.
Enteral services and in-home nutritional therapy (enteral or via gastrostomy tube) require prior authorization. Representative HCPCS codes: B4034–B4036, B4100–B4155, B4158–B4161, B9002, B9998, B9002, B9998.
Hearing aid services require prior authorization. Representative V-codes: V5171–V5267, V5299 and other hearing aid HCPCS codes listed in the hearing aid services section.
Home health care (outpatient settings including member's home) requires prior authorization for specified G- and S-codes: G0156, G0162, G0299, G0300, G0493–G0496, S9122–S9124. Hospice services require prior authorization (T2044, T2045).
Hysterectomy procedures require prior authorization. Representative CPT codes include 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290–58292, 58541–58544, 58550, 58552–58554, 58570–58573.
Infertility services require prior authorization. Representative CPT/HCPCS codes include 55870, 58825, 58970, 76948, 89254, 89257, 89259, 89264, 89337, 89398, and medication codes J0725, J3355 and applicable S-codes (S0122, S0126, S0128, S4028, S4042).
Joint replacement (total hip and knee) — prior authorization required for all inpatient stays and selected procedures/codes. Representative codes include 24360–24363, 24370–24371, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27446–27447, 27486–27487, 29866–29868, J7330, S2112.
Orthotics and prosthetics — prior authorization required only for orthotics/prosthetic codes with retail purchase or cumulative rental cost > $500. Representative L-codes include L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820, L1832, L1834, L1840, L1844–L1846, L1860, L1945, L1950, L1970, L7190–L7191, L7405, L8040–L8047, L8499, L8609–L8612, L8631, L8659.
Outpatient therapy for certain services requires prior authorization for members age 21 and older. Representative CPT codes include 92507, 92508, 92526 and others as listed in the outpatient therapy section.
Private duty nursing requires prior authorization. Representative T-codes: T1002, T1003.
Potentially unproven or investigational services require prior authorization. Representative codes include 33289, C2624 and others listed as Experimental/Investigational.
Prostate procedures require prior authorization for dates of service on or after April 1, 2022. Representative CPT codes include 37243, 53852, 52441, 55866, 52442, 53850.
Psychological testing requires prior authorization when billed with certain diagnosis codes as specified in the policy; representative CPT includes 89240 and other test codes when applicable.
Radiation therapy (standard 2D/3D) prior authorization is required only when obtained with specific cancer diagnosis codes (for example C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92) and for listed CPT codes such as 77401, 77402, 77407, 77412, 77470, 77525, 77387. Use the Radiology Prior Authorization resources on the provider site or call 866-889-8054.
Site of service (SOS) rules: prior authorization may be required only when services are performed in an outpatient hospital setting. Many procedures are not subject to PA if performed at a participating ambulatory surgery center (ASC). Refer to the SOS lists in the policy for procedure-level site restrictions (examples include cardiac, ophthalmologic, digestive system, colonoscopy, selected ear/auditory codes).
Sleep studies, spinal surgery, stimulators, neurostimulator implantation, and device implantations (including bone growth stimulators, neurostimulators, VADs, cochlear implants, ventricular assist devices) require prior authorization. Representative CPT/HCPCS codes include 95808, 95810, 95811, 22100–22114, E0747–E0760, 61863–61886, 63650–63685, 64561, 64640, L8680–L8688, L8682, L8685–L8687, and device HCPCS Q0507–Q0509 where noted.
Transplants and CAR T-cell therapy services require prior authorization. For transplant and CAR T-cell services (including Kymriah, Yescarta), contact the UnitedHealthcare Community and State Transplant team as directed in the policy.
Vein and varicose vein procedures require prior authorization for the listed CPT codes (e.g., 36468*, 36473, 36475, 36478, 37700, 37718, 37722, 37765–37766, 37780 and others). Note: some vein-related codes had prior authorization removed effective 04/01/24 — check the policy for current status.
Wound VACs require prior authorization. Representative HCPCS/HCPCS-related codes include E2402 and related wound therapy codes.
Additional operational notes:
- For oncology and chemotherapy-related PAs, use the Prior Authorization and Notification tile on UHCprovider.com or call 888-397-8129; for radiology PAs use 866-889-8054; for transplant/CAR-T follow transplant team instructions. For other services, use the portal or the number on the member ID card.
- The Review at Launch for New to Market Medications Policy lists newly approved medications and PA requirements; pre-determination is recommended for those drugs.
- This consolidated list is illustrative of the policy’s part 13 requirements — always confirm current code-level PA requirements and site-of-service rules on the UnitedHealthcare Provider Portal Prior Authorization and Notification Resources pages before scheduling or billing.