Colorado Rocky Mountain Health Plans Prior Auth

Prior authorization coverage criteria (partial list)

Selected categories require prior authorization and include example CPT/HCPCS codes; providers should use the Provider Portal or listed phone numbers to request authorization.

Bariatric surgery requires prior authorization; Centers of Excellence requirement applies. Example CPT codes: 43644, 43775, 43645, 43842, 43659, 43845, 43770, 43846.

Behavioral health services require prior authorization; contact the number on the member's health plan ID card for specific prior authorization/referral instructions.

Bone growth stimulators require prior authorization. Example CPT/HCPCS codes: 20975, 20979, E0760.

Breast cancer (BRCA) genetic testing requires prior authorization. Example CPT codes: 81162, 81432 (additional related codes listed).

Cardiovascular procedures (including specified cardiovascular CPTs such as 37225–37231) and cartilage implants require prior authorization; see cardiology prior authorization program for specific CPT lists.

Injectable chemotherapy and cancer supportive care drugs administered in outpatient settings require prior authorization. Example drug ranges/codes: J9000–J9999, Leucovorin (J0640), Levoleucovorin (J0641/J0642), Lupron Depot (J1950), Q-codes for certain agents.

Prior authorization requirements (partial)

Listed services and codes in this excerpt are marked as requiring prior authorization or having additional information; this is not a coverage decision table but an authorization requirement listing (partial).

Durable medical equipment (DME) codes listed require prior authorization; examples include A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445 (additional L-/E-/K- codes in list).

Enteral services require prior authorization. Example HCPCS codes: B9002, B9998.

Experimental and investigational services listed require prior authorization; example CPT/HCPCS codes shown (e.g., 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000).

Femoroacetabular impingement (FAI) syndrome procedures require prior authorization. Example CPT codes: 29914, 29915, 29916.

Functional and endoscopic sinus procedures require prior authorization. Example CPT codes: 31240, 31253–31259, 31267, 31276, 31287–31288.

Prior authorization and notification requirements (partial)

Partial list of services and codes that require prior authorization or notification per this document segment.

Gender dysphoria treatments and related surgical procedures: prior authorization required. Examples: 14000, 14001, 14040, 14302, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 54125, 54520, 54660, 54690, 55175, 55180.

Genetic and molecular testing: prior authorization required for listed tests; BRCA testing requires prior authorization/notification before DNA sequencing. Example molecular/genetic CPTs: 81228, 81229, 81277, 81400 (and related molecular codes).

Home health care services require prior authorization. Example CPT/HCPCS: G0299, G0495, G0300, G0496, G0493, S9474, G0494.

Hysterectomy procedures require prior authorization. Example CPT codes: 58150, 58152, 58180, 58260, 58263, 58267, 58270, 58290, 58291, 58292, 58541–58544, 58550, 58552–58554, 58570–58571.

Many injectable medications listed in the document require prior authorization; extensive J-/Q- code listings are provided (examples include Actemra J3262, Acthar J0801, J1427 [Vimizim], J1322, and others).

Coverage/authorization placeholders

Fragment lists codes and associated product names and indicates locations where prior-authorization process info would be provided (placeholders present).

Document fragments include placeholder lines for instructions on how to obtain prior authorization (e.g., 'how to obtain prior authorization = .') indicating missing or repeated placeholders in the source.

Specific biologic/drug references and HCPCS codes appear alongside placeholders for authorization instructions; repeated examples include J1427 (Vimizim®), J1322 (Vimizim/Vyepti references), and Viltepso® entries.

Prior authorization criteria (partial)

Selected items require prior authorization per the document excerpt.

Joint total hip and knee replacement procedures require prior authorization for the listed CPT codes. Examples include: 24360–24363, 24370–24371, 27120, 27125, 27130, 27132, 27134, 27137, 27486, 27487.

Certain musculoskeletal procedures and related injectable items require prior authorization; examples in the musculoskeletal section include CPTs 23472–23474, 29866–29868 and HCPCS J7330.

Selected injectable medications are listed with prior authorization indicated; example HCPCS: J3032 (Vyjuvek™), J3401 (additional injectable code).

Prior authorization coverage criteria (listed services)

Items and services in this section that require prior authorization include:

Non-emergent air ambulance transport requires prior authorization. Example HCPCS codes: A0430, A0435, A0436 (and related transport codes S9960/S9961).

Orthognathic surgery (maxillofacial/jaw procedures) requires prior authorization. Example CPT codes: 21121, 21123, 21125, 21127, 21141–21147, 21150–21155, 21159, 21160.

Orthotics and prosthetics: prior authorization required only for items with a retail purchase or cumulative rental cost greater than $500. Example L-code entries: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629.

Prior authorization required — assorted procedures

For the CPT/HCPCS codes listed below, prior authorization is required as indicated in this section.

Pain management procedures require prior authorization. Example CPT codes: 62350, 62351, 62360, 62361, 62362.

Prostate procedures require prior authorization. Example CPT codes: 37243, 52441, 52442, 53850, 53852, 55873, 55874.

Radiation therapy requires prior authorization. Example CPT codes: 77520, 77522, 77523, 77525; advanced outpatient imaging requires prior notification prior to scheduling via the Prior Authorization and Notification tool.

Rhinoplasty and shoulder surgery procedures require prior authorization. Example CPTs: Rhinoplasty 30400–30465; Shoulder surgery 29805–29828.

Sinuplasty and sleep apnea procedures require prior authorization. Example CPTs: Sinuplasty 31295–31298; Sleep apnea 21685, 41599, 42145.

Example CPT/HCPCS/ICD-10 Codes Referenced (Partial Lists)

Bariatric surgery example CPT codesCPTCovered

43644	Bariatric surgery code listed as requiring prior authorization
43775	Bariatric surgery code listed as requiring prior authorization

BRCA genetic testing example codesCPTCovered

81162	BRCA genetic testing code listed as requiring prior authorization
81432	BRCA genetic testing code listed as requiring prior authorization

Injectable chemotherapy and colony-stimulating factor drugsHCPCSCovered

J9000-J9999	Range for chemotherapy injectable drugs requiring prior authorization
J1442	Filgrastim (Neupogen) HCPCS code listed for colony-stimulating factors requiring prior authorization
Q5101	Biosimilar Zarxio listed among colony-stimulating factors requiring prior authorization

Cochlear and auditory implantsmixedCovered

69710	Cochlear implant code requiring prior authorization
69930	Cochlear implant code requiring prior authorization
L8614	HCPCS cochlear implant device code listed

Partial ICD-10 C44 series (selected)ICD-10

C44.191	Skin cancer/malignant neoplasm related code referenced with prior authorization
C44.1921	Related C44 series code
C44.1922	Related C44 series code

Selection of HCPCS/DME codes (partial)HCPCS

E0277	DME HCPCS code (example from list)
K0863	Orthotics/prosthetics related K-code (example)
V5283	Supply/V-code example

Injectable medications (partial list)HCPCS

J3262	Actemra (HCPCS J-code)
J0801	Acthar (HCPCS J-code)
J0225	Amvuttra (HCPCS J-code)
J0172	Aduhelm (HCPCS J-code)
J1931	Aldurazyme (HCPCS J-code)
Q5121	Avsola (HCPCS Q-code)
J0717	Cimzia (HCPCS J-code)
J0585	Botulinum toxin (HCPCS J-code family)

Genetic and molecular testing (partial)mixed

81228	Genetic test (CPT) listed for prior authorization
81479	Molecular pathology (CPT) listed for prior authorization

HCPCS drug codes referencedHCPCS

J1427	Listed in document alongside Vimizim/Vyepti/Viltepso
J1322	Listed in document alongside Vimizim/Vyepti/Viltepso

listed_codesmixedCovered

J1322	Vyepti® / Vimizim® referenced in document
J3032	Vyjuvek™ (injectable medication)
J3401	Associated injectable medication code listed
24360-24363,24370-24371	Joint replacement related CPT codes (as listed)
27120,27125,27130,27132,27134,27137	Total hip and related procedures
27486,27487,29866,29867,29868	Knee/arthroscopy/musculoskeletal procedure codes
J7330	Musculoskeletal injectable code listed
23472-23474	Musculoskeletal procedure codes listed

Representative CPT/HCPCS codes in this sectionmixed

J3032	Vyjuvek™ (injectable) listed
J3401	Injectable medication code
A0430	Non-emergent air ambulance
A0436	Non-emergent air ambulance
S9960	Ambulance transport code
L0112	Orthotics/prosthetics code (examples of many L-codes listed)

Durable medical equipment L-codes (partial list)HCPCS

L5812
L5814
L5816
L5818
L5822
L5824

Misc L-codes (partial)HCPCS

L8040
L8042
L8043
L8044
L8045

inv-21: DME prior authorization dollar threshold

DME prior authorization dollar threshold$500

Source contextDurable medical equipment (DME) — Additional information notes $500 threshold for prior authorization

Applies toRetail purchase or cumulative rental scenarios for DME items as listed in document

inv-22: DME rental cost threshold

DME rental cost threshold (document fragment)rental cost of more than — (value not completed in excerpt)

Source contextChunk indicates 'rental cost of more than' as partial text for DME additional information but amount not completed in provided excerpt

Related noteFull rental-cost threshold appears to be discussed alongside retail/cumulative thresholds in DME section; verify in full policy for exact value

inv-23: BRCA testing

BRCA testing requirementNotification/prior authorization required before DNA sequencing is performed

Ordering responsibilitiesThe ordering care provider must notify the laboratory conducting the test; the laboratory will notify UnitedHealthcare

Relevant codes (examples)0285U–0300U and other molecular test CPT/HCPCS codes listed in document around BRCA/molecular testing

inv-24: Orthotics/prosthetics prior authorization threshold

Orthotics/prosthetics prior authorization thresholdRetail purchase or cumulative rental cost > $500

Examples of affected codesL0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, etc.

ScopePrior authorization required only for orthotics and prosthetics meeting the retail or cumulative rental cost threshold

Submission Methods and What Providers Must Do

Prior Authorization

Submission methods and general prior authorization rule

For prior authorization, submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com > Sign In > Prior Authorization and Notification) or call 877-440-9946. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services except emergent or urgent care.

Prior Authorization

Cardiology prior authorization

Cardiology procedures and office-based electrophysiology implants require prior authorization. Submit requests via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054; see Minnesota's Cardiology Prior Authorization and Notification Program for specific CPT codes.

Prior Authorization

Service categories requiring prior authorization (examples)

Many specific service categories are identified as requiring prior authorization, including bariatric surgery, behavioral health services, bone growth stimulators, BRCA genetic testing, and cancer supportive care (e.g., colony‑stimulating factors and certain chemotherapy injectable drugs).

Bariatric surgery: Prior authorization required; Centers of Excellence requirement for coverage (example CPT codes: 43644, 43775).
Behavioral health services: Prior authorization required; refer to the number on the member's ID card for specific referral/prior authorization instructions.
Bone growth stimulators: Prior authorization required (example CPT/HCPCS codes: 20975, 20979, E0760).
BRCA genetic testing: Prior authorization required (example CPT codes: 81162, 81432).
Cancer supportive care: Prior authorization required for colony‑stimulating factor drugs and certain chemotherapy injectables; specific J/Q codes listed.

Prior Authorization

DME prior authorization (partial list)

The listed durable medical equipment (DME) HCPCS codes require prior authorization; the DME section notes prior authorization is required only for DME and references retail purchase or cumulative rental cost thresholds.

Examples of DME HCPCS codes requiring prior authorization include A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445.
Additional note: some DME items are subject to prior authorization only when retail purchase or cumulative rental costs exceed specified thresholds.

Prior Authorization

Enteral services prior authorization

Enteral services (HCPCS B9002, B9998) require prior authorization.

Prior Authorization

Experimental / investigational prior authorization

Services listed as experimental or investigational in the document are designated as requiring prior authorization.

Example CPT/HCPCS codes marked as experimental/investigational and requiring prior authorization include 33477, 36514, 64722, 65765, 65767, 66180, A4638, A6000.

Prior Authorization

FAI prior authorization

Femoroacetabular impingement (FAI) syndrome procedures (CPT 29914, 29915, 29916) require prior authorization.

Prior Authorization

Functional / endoscopic sinus prior authorization

Functional and endoscopic sinus procedures require prior authorization; listed CPT codes include 31240, 31253–31259, 31267, 31276, 31287–31288.

Prior Authorization

Gender dysphoria prior authorization

Gender dysphoria‑related procedures and associated treatment codes are designated as requiring prior authorization; multiple CPT codes are listed in the policy.

Example CPT codes listed for gender dysphoria requiring prior authorization include 14000, 14001, 15734, 19303, 53410, 54125, 54660, 55175, among others.

Prior Authorization

Prior authorization / notification

Prior authorization (and notification for some items) is required for multiple listed procedures, many genetic/molecular tests, home health, hysterectomy and numerous injectable medications; BRCA testing specifically requires prior authorization before DNA sequencing.

Genetic/molecular testing: some tests require notification or prior authorization (e.g., BRCA testing requires notification/prior authorization before DNA sequencing).
Injectable medications and many procedures: numerous J- and Q-codes and CPT codes in the document are marked 'Prior authorization required.'

Documentation Required

Prior authorization codes — sample entries

The document lists sample HCPCS drug entries showing how codes are presented; examples include J1427 (Vimizim®) and J1322 in the prior authorization entries.

Example HCPCS entries shown: J1427 (Vimizim®) and J1322.

Prior Authorization

Prior Authorization — selected injectable meds and joint replacement procedures

Prior authorization is required for the listed joint replacement procedures (total hip and knee replacement CPT codes such as 27120, 27130, 27486, etc.) and for multiple injectable medications (examples: J3032, J3401, J1322).

Joint replacement CPT codes listed with 'Prior authorization required' include 24360–24363, 24370–24371, 27120, 27125, 27130, 27132, 27134, 27137, 27486, 27487, 29866–29868.
Injectable medication HCPCS codes listed include J3032 (Vyjuvek™), J3401 and J1322.

Prior Authorization

Injectable medications (cont.)

Injectable medication entries in the policy continue across sections; Vyjuvek™ (J3032) and associated injectable HCPCS codes are listed and prior authorization is noted elsewhere for injectable drugs.

Example injectable code listed: J3032 (Vyjuvek™).

Prior Authorization

Joint replacement / Musculoskeletal procedures

Joint, total hip and knee replacement procedures and related musculoskeletal procedure codes are labeled 'Prior authorization required' in the document (examples: 27120, 27130, 27486, 29866–29868).

Prior Authorization

Non-emergent air ambulance transport

Non‑emergent air ambulance transport and ambulance transport codes (e.g., A0430–A0436, S9960, S9961) are listed with 'Prior authorization required.'

Prior Authorization

Orthognathic surgery

Orthognathic (maxillofacial/jaw) surgery CPT codes (e.g., 21121, 21123, 21125, 21127, 21141–21147, 21150–21159) require prior authorization.

Prior Authorization

Orthotics and prosthetics - prior authorization threshold

Orthotics and prosthetics codes listed require prior authorization only when the retail purchase or cumulative rental cost is more than $500; many L-codes are provided as examples.

Prior authorization threshold: retail purchase or cumulative rental cost > $500.
Examples of orthotics/prosthetics HCPCS codes listed: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629.

Prior Authorization

Pain management prior authorization

Pain management procedures (e.g., CPT 62350–62362) require prior authorization as listed.

Prior Authorization

Prostate procedures prior authorization

Prostate procedures identified in the list (for example CPT 37243, 52441, 52442, 53850) require prior authorization.

Prior Authorization

Radiation therapy prior authorization

Radiation therapy CPT codes (e.g., 77520, 77522, 77523, 77525) require prior authorization and health care professionals ordering advanced outpatient imaging procedures must provide notification prior to scheduling using the Prior Authorization and Notification tool.

Examples: 77520, 77522, 77523, 77525.
Advanced outpatient imaging: provider notification required prior to scheduling via the Provider Portal tool.

Prior Authorization

Rhinoplasty prior authorization

Rhinoplasty CPT codes (e.g., 30400, 30410, 30420, 30430, 30435) are listed as requiring prior authorization.

Prior Authorization

Shoulder surgery prior authorization

Shoulder surgery CPT codes listed (e.g., 29805–29807, 29819–29828) require prior authorization.

Prior Authorization

Sinuplasty prior authorization

Sinuplasty CPT codes (31295–31298) require prior authorization.

Prior Authorization

Sleep apnea prior authorization

Sleep apnea procedures (examples: CPT 21685, 41599, 42145) require prior authorization as indicated in the document.

Prior Authorization

Spinal surgery prior authorization

Spinal and related surgeries require prior authorization for the extensive list of CPT codes provided (examples include 20930, 22100, 22510–22513, 22600–22612, 22800–22861, 63001–63102, etc.).

Sample spinal CPT codes listed with prior authorization required: 20930, 20931, 20939, 22100–22114, 22206–22224, 22510–22515, 22600–22633, 22800–22899, 63001–63102.

Prior Authorization

Stimulators/device implantation prior authorization

Implantable stimulators and related device implantation procedures are listed as requiring prior authorization; numerous CPT and HCPCS device codes are provided (examples include 64553, 64555, 63650, 63655, L8680–L8688, 0312T–0317T).

Examples: 63650, 63655, 63685, 64553, 64555, 64568, 64570, 64590; HCPCS device codes L8680, L8682–L8688; temporary codes 0312T–0317T.
Prior authorization required for implantation of devices that send electrical impulses (E0749 referenced).

Prior Authorization

Transplant and CAR-T prior authorization

Transplant and CAR‑T cell therapy services are identified as requiring prior authorization; the transplant section begins in the document and indicates prior authorization is required.

The document notes 'Transplants Additional Information Prior authorization required' and that prior authorization applies to transplant and CAR‑T services (codes and detailed instructions appear in the section).

Key Terms and Notices

inv-52: Prior authorization

DefinitionPrior authorization — Request approval before rendering a service, as required by UnitedHealthcare policy

When not requiredNot required for emergency or urgent care

Submission methodsSubmit via Prior Authorization and Notification tool on UHCprovider.com or call 877-440-9946

inv-53: Advance notification / exceptions

Advance notification purposeAdvance notification required to allow UnitedHealthcare to perform prospective, concurrent and retrospective care review

ExceptionAdvance notification is not required for emergency or urgent care

Provider requirementOut-of-network providers must request prior authorization for all procedures and services except emergent or urgent care

inv-54: DME

DefinitionDurable medical equipment (DME) — Items listed with HCPCS codes in DME section that may require prior authorization

Operational noteSome DME codes are subject to retail purchase or cumulative rental thresholds for prior authorization

Example HCPCSE0470, E0471, E0483, E0486, E0620 (among others listed)

inv-55: Experimental and investigational

DefinitionExperimental and investigational — Services/procedures not routinely covered without specific authorization (prior authorization required)

Document noteExperimental/investigational items in the list are marked 'Prior authorization' or 'required'

ExamplesCPT codes 33477, 36514, 64722, 65765, 66180 listed as investigational with prior authorization requirement

inv-56: Gender dysphoria treatments / certain procedures

RequirementGender dysphoria-related procedures require prior authorization

Examples of proceduresCPT codes listed include 14000, 14001, 14302, 15734, 19303, 54125, 55175, among others

ScopeApplies to gender dysphoria treatment procedures and associated codes shown in the document

inv-57: Genetic and molecular testing

RequirementNotification/prior authorization required for some genetic and molecular tests

Ordering processOrdering provider must notify the laboratory; the laboratory will notify UnitedHealthcare

ExamplesCPT codes referenced include 81228, 81229, 81277, 81400 and a series of molecular test codes (0285U–0300U) listed in document

inv-58: Vimizim

ProductVimizim® (referenced with HCPCS J1427/J1322 in document)

ContextListed among injectable/HCPCS drug entries with prior authorization references

Related codesDocument cites J1427 and J1322 alongside Vimizim/Vyepti/Viltepso

inv-59: Vyepti

ProductVyepti® (referenced with HCPCS J1322 in document)

ContextAppears multiple times in injectable medication listings that include prior authorization instructions

Related codesJ1322 is cited in the document associated with Vyepti/Vimizim entries

inv-60: Viltepso

ProductViltepso® (mentioned alongside J1427 and Vimizim in document)

ContextIncluded in the list of drug/product names paired with HCPCS codes and prior authorization notes

Related codesDocument lines list Viltepso with J1427 and other injectable entries

inv-61: Prior authorization

RequirementPrior authorization required — obtain plan approval before scheduling or performing listed procedures/services

How to submitUse UHCprovider.com Prior Authorization and Notification tool or call 877-440-9946

ExceptionNot required for emergency or urgent care

inv-62: Orthotics and prosthetics prior auth threshold

ThresholdPrior authorization required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500

Example L-codesL0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637

ApplicationApplies to orthotics/prosthetics entries in document; items below threshold do not require prior authorization per the listed note

inv-63: Prior authorization

Plan approval requiredPrior authorization — prior approval from the plan required before scheduling or performing listed services

Submission channelsSubmit via Provider Portal Prior Authorization and Notification tool or call designated phone number

Refer to codesSee CPT/HCPCS code lists in document for services that require prior authorization

inv-64: CPT/HCPCS codes

DefinitionCPT/HCPCS codes — Procedure and supply codes listed correspond to services which may require prior authorization per the plan

UsageCodes shown throughout the document indicate services requiring prior authorization and should be used when submitting requests

ExamplesMultiple CPT and HCPCS codes (e.g., spinal surgery codes 20930–22224, L-codes) are listed in the policy excerpts

OpenPayer

Prior authorization requirements for Minnesota Medicaid

Services and Procedures Requiring Prior Authorization (Partial List)

Example CPT/HCPCS/ICD-10 Codes Referenced (Partial Lists)

Submission Methods and What Providers Must Do

Key Terms and Notices