CurrentColorado Rocky Mountain Health PlansPolicy PCA-2-24-01315-Clinical-QRG_07182024

Prior Authorization Quick Reference — UnitedHealthcare Mid-Atlantic Health Plans

This document lists prior authorization requirements and related instructions for participating UnitedHealthcare Mid-Atlantic Health Plans providers for inpatient and outpatient services; it explains how to submit requests and notes exceptions for emergency/urgent care and out-of-network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Quick Reference — UnitedHealthcare Mid-Atlantic Health Plans

Policy CodePolicy PCA-2-24-01315-Clinical-QRG_07182024

Change TypeNo material change

Effective DateAug. 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PCA-2-24-01315document identifier

Aug. 1, 2024effective date

Online/chatsubmission methods

ManyPA required

8 visits

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.

therapy initial referral

Coverage Criteria and Prior Authorization Requirements

Coverage overview and specific criteria notes

General coverage stance and notable criteria from this portion of the document:

Prior authorization is required for elective services; emergency or urgent care is exempt and out-of-network providers must still request prior authorization.

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID) or via 24/7 chat on the Contact us page.

It is the physician's responsibility to obtain relevant prior authorization; facilities must verify coverage approval is on file before performing elective services to avoid denial of payment.

Certain services listed (e.g., bariatric surgery, bone growth stimulators, BRCA genetic testing, breast reconstruction) have code- and diagnosis-specific prior authorization requirements as enumerated in the policy.

PA exemptions by diagnosis

Diagnoses for which prior authorization is not required (ICD-10 list excerpt):

Prior authorization is not required for the long list of specified diagnosis codes related to breast cancer and related codes (examples appear in the document's ICD-10 lists).

Procedural PA requirements

Procedures requiring prior authorization:

Breast reconstruction (non-mastectomy) procedures require prior authorization for the listed CPT/HCPCS codes (examples include 15771, 19300–19369, 19370–19371, 19396, L8600).

BRCA and other genetic testing codes require prior authorization and a genetic counseling attestation per Oncology Prior Authorization resources.

Examples

Bone growth stimulator codes (20974–20979) require prior authorization.
Bariatric surgery codes (e.g., 43860, 43865, 43886–43888) require prior authorization with diagnosis-code-specific rules.

Site-of-service review may apply for certain procedural codes as noted in the policy.

Injectable medication PA requirements

Injectable medications requiring prior authorization for outpatient administration in cancer diagnoses (and some for non-oncology when noted):

Prior authorization is required for outpatient injectable chemotherapy drugs (J9000–J9999), colony-stimulating factors, and specified anti-emetics and supportive agents when billed for a cancer diagnosis.

Examples of colony-stimulating and supportive agents that require prior authorization include: J0897 (denosumab), J1442 (filgrastim), J2506 (pegfilgrastim) and multiple Q-codes (Q5101, Q5110, Q5111, Q5120, Q5122, Q5125).

Anti-emetics listed that require prior authorization include J1449 (eflapegrastim? listed), J1454 (Akynzeo), J0185 (Cinvanti), J1453/J1456 (Emend) and J1627 (Sustol).

Some Q-coded supportive drugs (Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) also require prior authorization for non-oncology diagnoses per the policy notes.

Prior authorization requests for these injectable medications should be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (or by calling the listed phone number where provided).

Partial prior authorization criteria (by service)

Service-specific prior authorization stance (partial):

Chemotherapy injectable drugs administered outpatient require prior authorization (includes J9000–J9999 and specified J/Q codes and related miscellaneous HCPCS billing), and chemotherapy-related PA submissions use the Provider Portal.

Inpatient video seizure monitoring (CPT codes 95700–95718 series as listed) requires prior authorization for inpatient services.

Cartilage implant procedures (examples: 27412, 27415, 27416, 29866–29868, J7330, S2112) require prior authorization.

Cochlear and related hearing device services (e.g., 69710, 69714, 69930, L8614, L8692) require prior authorization.

Clinical trials services billed with S9988, S9990, S9991 require prior authorization.

Cosmetic/reconstructive procedures exceptions

Cosmetic and reconstructive procedures: prior authorization required except when billed with specified diagnosis codes.

Cosmetic and reconstructive procedure CPT/HCPCS codes require prior authorization for all states unless an allowed diagnosis code is billed (the policy lists numerous diagnosis exceptions where PA is not required).

The policy provides extensive ICD-10 diagnosis lists that exempt certain cosmetic/reconstructive procedures from prior authorization when billed with those diagnoses.

DME authorization criteria

DME prior authorization applies to listed codes and when cumulative rental or retail purchase exceeds thresholds; some items/prosthetics have special rules.

Prior authorization is required for the listed DME codes and for items whose retail purchase or cumulative rental cost exceeds $1,000.

Examples

Power mobility and certain devices require prior authorization regardless of cost (examples: E0745, E0784).
Some orthotics and orthotics-related L-codes require authorization when retail purchase or cumulative rental thresholds are met.

The document enumerates many specific DME and K-/E-/A- codes subject to PA; refer to the listed codes in the policy for exact billing codes.

Continuous glucose monitor coverage stance

Continuous glucose monitors require prior authorization when associated with a type 2 diabetes diagnosis.

Continuous glucose monitor supplies and devices (examples: A4226, A4238, A4239, A9276–A9278, E0787, E2102–E2103) require prior authorization when billed with a type 2 diabetes diagnosis.

Prior authorization required — listed services

Prior authorization required for the following services and codes as listed in the document fragment:

End-stage renal disease (ESRD) dialysis services (CPT 90935, 90937, 90945, 90947, 90999 and related J/HCPCS codes) require prior authorization; PA contact via chat is provided.

Functional endoscopic sinus surgery (FESS) and specified foot surgery codes require prior authorization; site-of-service review applies for listed codes.

Home health in-home nursing services (T1000, T1002) require prior authorization for in-home non-nutritional nursing services.

Numerous injectable medication codes (various J-codes) across hematologic/oncology and other therapeutic areas require prior authorization as listed in the policy.

MRgFUS coverage conditions

MR-guided focused ultrasound (MRgFUS) for uterine fibroid — conditional coverage for certain plans with provider/facility and member requirements.

MRgFUS to treat uterine fibroid is covered only for certain benefit plans and is subject to conditions: physician/facility must confirm coverage for the member, the facility must be contracted with UnitedHealthcare, the member must have no out-of-network benefits and must consent in writing, and the physician/facility must demonstrate experience and follow FDA-labeled indications.

UnitedHealthcare states there is insufficient peer-reviewed evidence to broadly conclude safety/effectiveness and requires the member to agree in writing not to hold UnitedHealthcare responsible if unsatisfied with results as a condition for coverage under applicable plans.

Inpatient and surgical services prior authorization

Inpatient post-acute services, orthognathic surgery, orthotics — prior authorization required; orthognathic must follow FDA labeled indications.

Prior authorization and notification of admission date are required for post-acute inpatient services including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities.

Orthognathic/maxillofacial surgery (examples: 21050, 21060, 21121, 21123, 21125–21147 and related codes) requires prior authorization; procedures must follow FDA-labeled indications for use.

Orthotics listed require prior authorization only for orthotics codes with a retail purchase or cumulative rental cost over the stated threshold; specific L-codes and orthotics codes are enumerated in the policy.

Non-emergency air transport coverage

Non-emergency air transport — prior authorization required; specific HCPCS codes listed.

Non-emergency air transport (non-urgent ambulance transportation by air) requires prior authorization; HCPCS codes include A0430, A0431, A0435, A0436 and related S-codes as listed.

Out-of-network referral authorization

Out-of-network services — prior authorization required when a network provider directs a member to out-of-network care and plan allows out-of-network benefits; members may face increased out-of-pocket costs or no coverage.

When a network physician or health care professional directs a member to an out-of-network facility, physician or other health care professional, prior authorization is required if the member's plan allows out-of-network benefits.

Members who use out-of-network providers may have increased out-of-pocket expenses or no coverage; providers should verify plan benefits and obtain prior authorization when applicable.

Pain management injections

Pain management injections — prior authorization required; CPT codes 62320–62351 referenced.

Pain management injection procedures require prior authorization; referenced CPT codes include 62320–62327, 62350–62351 and additional nerve block/injection codes (e.g., 64451, 64484, 64520, 64620, 64640) as listed.

Out-of-network services prior authorization

Out-of-network referrals and services prior authorization requirements

Prior authorization is required when a network physician or health care professional directs a member to an out-of-network facility/provider and the member's plan includes out-of-network benefits; verify member benefits and obtain PA to prevent potential coverage denial or higher member cost.

Therapy coverage and authorization rules

Outpatient rehabilitation (physical, occupational, speech) coverage criteria

Prior authorization is required for outpatient physical, occupational and speech therapy for OptumHealth network and out-of-network providers after initial referral limits are exhausted.

Initial referral for physical or occupational therapy is valid for up to 8 visits per condition within 6 months from the referral date; if the referral does not indicate number of visits it is valid for one visit. Additional visits beyond the initial 8 require prior authorization.

For facilities, authorization must be obtained prior to the first visit. Prior authorization requests for therapy-related services cannot be submitted online per the policy.

Prosthetics authorization criteria

Prosthetics prior authorization criteria based on purchase/rental cost

Prior authorization is required only for prosthetic codes with a retail purchase or cumulative rental cost of more than $1,000; the policy enumerates specific L-codes subject to this threshold.

Radiation/radiology authorization criteria

Radiation and radiology services requiring prior authorization and diagnosis-based exceptions for cancer

Radiation therapy and many radiology services require prior authorization; submission instructions are provided via the UnitedHealthcare Provider Portal Radiology/Cardiology/Oncology/Radiation Therapy pathways.

Included services

SRS/SBRT and related radiation therapy procedures (codes such as 77371–77373, G0340, G0339) require prior authorization.
Imaging services including CT and MRI scans and other advanced radiology procedures are subject to prior authorization as listed in the Radiology section.

Some radiation and radiology PA requirements vary by clinical indication (for example, cancer-related services may be handled under different cancer-specific pathways); check the Radiology/Oncology submission guidance in the portal.

Prior authorization criteria (partial)

Procedures and codes listed herein require prior authorization as indicated.

Many listed surgical and implantable device CPT/HCPCS codes require prior authorization for all states (the policy lists numerous examples across specialties).

Site-of-service review will be part of the prior authorization process for specified codes except in exempt states/territories: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

Spinal cord stimulator implantation for pain management requires prior authorization for all states; specific CPT and L-codes (e.g., 63650, 63655, 63662, 63664, 63685, 63688, 64553, 64570 and L8679–L8688 series) are enumerated.

For certain high-complexity procedures and implantable devices, contact or notification instructions are provided where applicable (e.g., transplant and specialized device coordination).

Prior authorization requirement

Codes and services in this segment are designated as requiring prior authorization or notification.

Examples

A-codes related to treatment of disease and varicose veins of the extremities (examples: A9513, A9590, A9606, A9607, A9699) require prior authorization.
Cardiac/mechanical pump and related procedures (examples: CPT 33976, 33927, 33929, 33975, 33983 and Q-codes Q0507–Q0509) require prior authorization and may include notification instructions to call the number on the member's health plan ID card.

The policy repeats that prior authorization is required for numerous listed services and codes across the document; providers should review code lists and follow submission instructions in the Provider Portal or contact numbers provided.

CPT/HCPCS/ICD-10 Code Lists and Coding Notes

Selected CPT codes for rhinoplasty and sinuplastyCPTCovered

30400-30462	Rhinoplasty series (includes 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462), prior authorization required for rhinoplasty when indicated
31295	Sinuplasty, prior authorization required
31296	Sinuplasty, prior authorization required
31297	Sinuplasty, prior authorization required

Injectable/supportive agents (examples)HCPCSCovered

J1449	Erythropoiesis-stimulating agent (example listed)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)
J2820	Sargramostim (Leukine)

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Anti-emetics requiring prior authorizationHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon) listed in anti-emetic/hematologic section
J1454	Akynzeo (palonosetron/fosnetupitant)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1456	Emend (alternative code)
J1627	Sustol (granisetron extended release)

Sample ICD-10-CM codes appearing in this segmentICD-10

S81.801A	Open wound of unspecified thigh, initial encounter (example)
S91.301A	Open wound of unspecified toe(s), initial encounter (example)
M86.051	Acute osteomyelitis of right shoulder (example)
I27.83	Pulmonary hypertension due to other specified disease

Selected CPT codes for monitoring/seizure servicesCPTCovered

95700	EEG monitoring; complete, inpatient video (prior auth required)
95711	EEG monitoring, extended (prior auth required)
95712	EEG monitoring, additional leads
95713	EEG monitoring, continuous
95714	EEG monitoring, additional

Congenital heart disease Q-codes and related ICDsICD-10Covered

Q21.9	Congenital malformation of heart, unspecified
Q22.0	Transposition of great vessels
Q25.1	Aortic valve atresia/stenosis (example)

Continuous glucose monitor HCPCSHCPCSCovered

A4226	Continuous glucose monitor sensor
A4238	CGM transmitter
A9276	Implantable continuous glucose monitor
E0787	CGM device rental or specific code
E2102	CGM component (example)

Dialysis CPT codesCPTCovered

90935	Hemodialysis procedure with single evaluation
90937	Hemodialysis with multiple evaluations
90945	Peritoneal dialysis, fewer than 5 exchanges
90947	Peritoneal dialysis, with more exchanges
90999	Unlisted dialysis procedure
J0606	Post-dialysis infusion therapy (J-code example)
J0879	Post-dialysis infusion therapy (alternate)

Injectable medication J-codes (examples)HCPCSCovered

J3398	Hematologic agent (example)
J3399	Hematologic agent (example)
J3401	Hematologic agent (example)
J7170	Hemophilia agent example
J7175	Hemophilia agent example
J7177	Hemophilia agent example
J7178	Hemophilia agent example

Injectable medication HCPCS/J-codes (sample)HCPCSCovered

J7200	Injectable medication example
J7214	Injectable medication example
J0739	Vaccine administration (example)
90283	Immune globulin administration
90284	Immune globulin administration

Non-emergency air transport codesHCPCSCovered

A0430	Non-emergency air ambulance, basic life support
A0431	Non-emergency air ambulance, advanced life support
A0435	Air transport, with medical personnel
A0436	Air transport, other
S9960	Non-emergency air transport (specific)

Orthognathic/maxillofacial CPT codesCPTCovered

21050	Orthognathic procedure (example)
21121	Orthognathic maxillofacial procedure
21141	Maxillofacial reconstruction
21159	Orthognathic surgery code
21210	Maxillofacial reconstruction
21215	Maxillofacial reconstruction

Unclassified/temporary medication codesHCPCS

0098T	Temporary code example
0288U	Genetic testing U-code example
0029U	Genetic test U-code example

Cosmetic/reconstructive injectable codes (sample)CPTCovered

11960	Subcutaneous injection for cosmetic procedure
11970	Injection for cosmetic procedure
14020	Adjunctive skin repair (example)
14302	Tunneling of graft/implant (example)

Pain management / injection codesCPTCovered

62320	Injection(s), spinal canal (epidural)
62326	Injection(s), therapeutic, lumbar
64451	Paravertebral injection

Prosthetics codes (L-codes examples)HCPCSCovered

L5010	Prosthetic penile device component (example)
L5105	Prosthetic component (example)
L5681	Prosthetic component (example)

Radiation therapy / SRS/SBRT codesCPTCovered

77371	SRS/SBRT treatment delivery (example)
77372	SRS/SBRT fraction (example)
77373	SRS/SBRT planning (example)
G0340	SRS/SBRT delivery (HCPCS)

Miscellaneous surgical/procedural codesCPTCovered

64721	Carpal tunnel surgery (neuroplasty) — prior authorization noted in site-of-service list
66821	Cataract surgery (code referenced for site-of-service)
66982	Complex cataract surgery (prior authorization/site-of-service noted)
13101	Adjunctive skin procedures (cosmetic/reconstructive group)
14301	Tissue transfer procedures (example)
13132	Reconstruction procedures (cosmetic/reconstructive group)
21552	Excision, soft tissue of back or flank (example)
30520	Excision/repair procedures of nose (example)
21320	Facial fracture repair codes (example)

Sample listed CPT codesCPTCovered

69631	Tympanostomy with other procedure (example)
57522	Endometrial sampling with dilation and curettage (example)
58565	Hysteroscopy with sampling/biopsy (example)
49505	Hernia repair (example)
58353	Insertion of IUD (example)
58558	Hysteroscopy with removal (example)
58563	Hysteroscopy with operative procedures (example)

Spinal cord stimulator HCPCS/L-codesHCPCSCovered

L8679	Spinal cord stimulator implantable neurostimulator, single array
L8680	Spinal cord stimulator lead or component
L8682	Spinal cord stimulator lead/device

A-codes - varicose veins (example)HCPCSCovered

A9513	Vein ablation supplies (example)
A9590	Varicose vein supply (example)

Cardiac/mechanical pump codesCPTCovered

33976	Implantable mechanical circulatory support device — prior authorization required
33979	Mechanical pump related procedure
33983	Procedure on damaged ventricle (example)

Submission Instructions, Contact Points, and Actionable Requirements

Prior Authorization

Submission methods and general prior authorization rules

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (One Healthcare ID) or via 24/7 chat on the Contact us page. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services. Facilities must verify coverage approval is on file before performing elective services; payment may be denied without prior authorization.

Prior Authorization

Code-level prior authorization requirements (examples listed)

Numerous CPT/HCPCS codes listed in the document require prior authorization (examples include arthroplasty and arthroscopy codes such as 23470, 27132–27138, 27437–27447 and 29826/29843/29871; bariatric surgery ranges; bone growth stimulator codes 20974–20979; BRCA/genetic testing codes; and breast reconstruction codes 15771, 19300–19369). Site-of-service review applies for certain codes.

Prior Authorization

Definitions and Key Terms

Prior authorization — definition and scope

DefinitionPrior authorization is the approval a health plan provides before an elective service is performed; emergency/urgent care is exempt

Out-of-network providersOut-of-network physicians, facilities and other health care professionals must still request prior authorization for all procedures and services

ResponsibilityPhysician is responsible for obtaining PA; facility must verify approval is on file before elective services to avoid payment denial

Genetic counseling attestation

RequirementGenetic counseling attestation and supporting documentation are required prior to BRCA and certain genetic testing

Where to find formsGenetic counseling attestation form and supporting documentation available via Oncology Prior Authorization resources

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Quick Reference — UnitedHealthcare Mid-Atlantic Health Plans

Policy CodePolicy PCA-2-24-01315-Clinical-QRG_07182024

Change TypeNo material change

Effective DateAug. 1, 2024

Next Review Date

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat.

SourceLink

On This Page

Congenital heart disease and VAD-related services require prior authorization/notification and may require contacting Optum VAD Case Management at 888-936-7246 as noted.

Prior authorization submission instructions and required injectable PA

For prior authorization requests submit online using the Prior Authorization and Notification tool on UHCprovider.com (Sign In with One Healthcare ID) or call 888-397-8129. Prior authorization is required for outpatient injectable chemotherapy, colony-stimulating factors and listed anti-emetics/supportive agents (specific J/Q-codes are enumerated).

Examples of injectable/supportive codes requiring PA: J0897, J1442, J2506, Q5101, Q5110, Q5120, Q5122, Q5125 and others listed in the document.

Prior Authorization

Breast reconstruction prior authorization

Breast reconstruction (non-mastectomy) procedures require prior authorization for the listed CPT/HCPCS codes (examples include 15771 and 19300–19371, 19396 and L8600).

Documentation Required

Diagnoses exempt from prior authorization

Prior authorization is not required for the long list of specified diagnosis codes shown (ICD-10 breast cancer and related codes).

Prior Authorization

Prior authorization submission instructions (partial)

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (Sign In with One Healthcare ID); portal access instructions are provided on UHCprovider.com.

If needed, phone support is available at 888-397-8129 for certain services.

Prior Authorization

Clinical trials prior authorization requirement

Clinical trials billing codes S9988, S9990 and S9991 are listed with the note 'Prior authorization required.'

Prior Authorization

Selected procedures requiring prior authorization

Selected procedures and devices (for example cartilage implant and cochlear services) are flagged as prior authorization required; cochlear examples include CPT 69710, 69714, 69930 and HCPCS L8614/L8692.

Cartilage implant and cochlear device codes listed explicitly require prior authorization.

Note

VAD/ congenital heart disease notification

For congenital heart disease and ventricular assist device (VAD) management contact the Optum VAD Case Management Team at 888-936-7246 or call the notification number on the member's health plan ID card as instructed in the document.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitors require prior authorization when billed with a type 2 diabetes diagnosis; multiple HCPCS/HCPCS-like codes (for example A4226, A9276, A9277, E0787, E2102) are listed.

Prior Authorization

Cosmetic and reconstructive procedures prior authorization

Cosmetic and reconstructive procedure codes require prior authorization for all states unless specific diagnosis exceptions apply; numerous CPT codes are enumerated in the document.

Prior Authorization

DME prior authorization and cost thresholds

DME listed in the document requires prior authorization; cost-based rules apply—prior authorization is required for prosthetics or equipment when retail purchase or cumulative rental exceeds $1,000 and some items identified as prosthetics are not DME.

Examples of DME codes and prosthetic L-codes are listed throughout the DME/prosthetics sections.

Prior Authorization

ESRD dialysis prior authorization

Prior authorization is required for end-stage renal disease (ESRD) dialysis services; for prior authorization connect via chat through the Contact us page per the document instructions.

Examples of dialysis CPT and HCPCS codes listed: 90935, 90937, 90945, 90947, 90999, J0606, J0879; revenue and S-codes shown.

Prior Authorization

FESS and foot surgery prior authorization

Functional endoscopic sinus surgery (FESS) requires prior authorization; site-of-service will be reviewed as part of prior authorization for listed foot surgery codes as noted.

Examples of FESS CPT codes listed: 31240, 31253–31259, 31267, 31276, 31287–31298.

Prior Authorization

Gender dysphoria and related procedures prior authorization

Prior authorization is required for multiple gender dysphoria treatment and related reconstructive/cosmetic procedure codes regardless of diagnosis; the document lists specific CPT codes requiring authorization.

Example codes include 55970, 55980 and a range of reconstructive/cosmetic CPT codes.

Prior Authorization

Home health in-home nursing prior authorization

Prior authorization is required for home health in-home non-nutritional nursing services; listed CPT/HCPCS examples include T1000 and T1002.

Prior Authorization

Injectable medications prior authorization

Numerous injectable medications and specialty pharmacy drugs require prior authorization; the policy references submission via the Provider Portal Specialty Pharmacy Transactions tile or specialty pharmacy vendor processes and lists many J-/Q-codes.

Examples of injectable codes shown across sections (non-exhaustive): J0223, J1300, J9376, J3398, J0596, J3401 and many others.

Prior Authorization

Inpatient admissions - post acute services

Prior authorization and notification of the admission date are required for post-acute inpatient services including acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities.

Prior Authorization

Non-emergency air transport

Non-emergency air transport (non-urgent ambulance transportation by air between specified locations) requires prior authorization; listed HCPCS/CPT examples include A0430, A0431, A0435 and A0436.

Prior Authorization

Orthognathic surgery

Orthognathic surgery (treatment of maxillofacial functional impairment) requires prior authorization; follow U.S. FDA labeled indications for use per the policy.

Example orthognathic/maxillofacial CPT codes listed include 21050, 21060, 21121, 21123, 21125, 21127 and others.

Prior Authorization

Pain management injections

Pain management injection procedures require prior authorization; listed CPT codes include 62320–62327, 62350–62351 and related nerve block/injection codes.

Examples shown: 62320, 62322, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361.

Prior Authorization

MRgFUS for uterine fibroid

MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid is covered only for certain benefit plans and is subject to conditions: physician/facility must confirm member coverage, facility must be contracted with UnitedHealthcare, member must consent in writing, member must have no out-of-network benefits, provider/facility must demonstrate experience and procedure must follow FDA-labeled use.

Prior Authorization

Out-of-network services prior authorization

Prior authorization is required when a network physician or other health care professional directs a member to an out-of-network facility, physician or other health care professional and the member's plan has out-of-network benefits; members may have increased out-of-pocket expenses or no coverage.

Prior Authorization

Out-of-network referral prior authorization

When a network physician directs a member to a facility or provider who does not participate in the UnitedHealthcare network, prior authorization is required (per the Out-of-network referral rules).

Prior Authorization

Therapy prior authorization and referral limits

Outpatient physical, occupational and speech therapy provided by OptumHealth network or out-of-network providers require prior authorization after initial referral limits; the initial referral is valid for up to 8 visits per condition within 6 months and additional visits require pre-authorization. Facilities must obtain authorization prior to the first visit.

If a referral does not indicate number of visits it is valid for one visit only.

Documentation Required

Therapy prior authorization submission

Prior authorization requests for physical, occupational, speech and any other therapy-related services cannot be submitted online; follow the non‑online submission instructions in the policy.

Prior Authorization

Prosthetics prior authorization threshold

Prior authorization is required only for prosthetic codes with a retail purchase or cumulative rental cost of more than $1,000; the policy enumerates specific L-codes that trigger this threshold.

Examples of prosthetic L-codes listed in the policy are provided in the prosthetics section.

Prior Authorization

Radiation/radiology prior authorization and submission

Radiation therapy and many radiology services require prior authorization; submit online requests via the UnitedHealthcare Provider Portal 'Radiology, Cardiology, Oncology, and Radiation Therapy' workflow as described in the document.

Examples include radiation therapy/SRS/SBRT CPT/HCPCS codes (e.g., 77385, 77386, 77371–77373, G0340) listed in the radiology/radiation sections.

Prior Authorization

Spinal cord stimulator prior authorization

Spinal cord stimulators implanted for pain management require prior authorization in all states; specific CPT and HCPCS/L-codes are listed (for example 63650, 63655, 63662, 63664, 63685, 63688, 64553, 64570 and L8679/L8680 etc.).

Prior Authorization

Surgical procedure prior authorization and site-of-service review

Numerous surgical procedure and implantable device CPT/HCPCS codes are designated 'Prior authorization is required for all states.' Site-of-service will be reviewed as part of prior authorization for specified codes except in exempt states/territories.

Site-of-service exemptions: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

Documentation Required

Site-of-service exceptions

Site-of-service will be reviewed as part of prior authorization for certain codes except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin—providers in those jurisdictions are exempt from the site-of-service review requirement noted.

Note

Transplant / cellular & gene therapy notification

For transplant and certain cellular & gene therapy products (example Zynteglo, betibeglogene autotemcel) contact the number provided: call 888-936-7246 or the notification number on the member's health plan ID card.

Prior Authorization

A-code prior authorization for varicose veins

A-codes for treatment of disease and varicose veins of the extremities (examples include A9513, A9590, A9606, A9607, A9699) are listed as requiring prior authorization.

Prior Authorization

Cardiac/mechanical pump prior authorization and notification

Several CPT and Q-codes for cardiac/mechanical pump and related heart procedures are noted with 'Prior authorization required' and/or instruction to call the notification number on the member's health plan ID card (examples include 33976, 33983, 33927, 33929, 33975 and Q0507–Q0509 mappings).

Affected codesBRCA and other hereditary testing codes listed in genetic testing sections (e.g., 81162–81164, 81277, 81349 and various U/024xU codes)

Prior Authorization and Notification — submission

PortalUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) to submit PA requests

Phone optionOr call 888-397-8129 for assistance with PA requests

Chat option24/7 chat available via the Contact us page on UHCprovider.com for PA submission and help

Breast reconstruction (non-mastectomy)

ServiceBreast reconstruction (non-mastectomy) — reconstruction of the breast except when following mastectomy

PA requirementPrior authorization required for listed CPT/HCPCS breast reconstruction codes (e.g., 15771, 19300–19369, L8600)

ContextThese procedures are identified specifically as non-mastectomy reconstruction requiring PA

Clinical trials — definition and PA

DefinitionClinical trials: a rigorously controlled study of a new drug, device or other treatment on eligible human subjects under IRB oversight

PA statusClinical trial codes S9988, S9990, S9991 are listed with 'Prior authorization required'

SubmissionSubmit PA requests via the Provider Portal as directed for clinical trial services

Durable medical equipment (DME) and CGM

DefinitionDurable medical equipment (DME) — items and HCPCS codes listed in the DME section that may require PA

CGM noteContinuous glucose monitor HCPCS (A4226, A4238, A4239, A9276–A9278, etc.) require prior authorization when billed with a type 2 diabetes diagnosis

DME submissionDME PA requests follow standard prior authorization submission via Provider Portal

Continuous glucose monitor

DeviceContinuous glucose monitors (CGM) — specific HCPCS codes listed (A4226, A4238, A4239, A9276, A9277, A9278, E0787, etc.)

PA conditionPrior authorization required when billed with a type 2 diabetes diagnosis

ActionVerify PA prior to dispensing/claim submission to ensure coverage

Durable medical equipment (DME)

DME rulesDME prior authorization is required for listed DME codes; threshold and cost-based rules apply (e.g., > $1,000) and some prosthetics are not DME

ExamplesPower mobility, lymphedema pumps, and numerous K-/E- HCPCS codes listed in DME section

GuidanceReview DME-specific section for code-level PA instructions and thresholds

ESRD dialysis services

ServiceESRD dialysis services (hemodialysis, peritoneal dialysis) — outpatient dialysis services

PA requirementPrior authorization required for ESRD dialysis services; connect via chat through Contact us page for PA

Representative codesCPT examples: 90935, 90937, 90945, 90947, 90999; HCPCS: S9335, S9339

MRgFUS (MR-guided focused ultrasound)

ProcedureMR-guided focused ultrasound (MRgFUS) to treat uterine fibroid

Coverage conditionsCoverage limited to certain benefit plans: contracted facility, member consent in writing, demonstrated provider/facility experience, and FDA-labeled use

Plan stanceUnitedHealthcare generally considers evidence insufficient for broad coverage; confirm member benefits prior to scheduling

Out-of-network services — prior authorization

RequirementWhen a network provider directs a member to an out-of-network facility/provider and the member's plan allows out-of-network benefits, prior authorization is required

Member impactMembers may face increased out-of-pocket costs or no coverage for out-of-network services

Provider actionVerify member benefits and obtain PA before directing to out-of-network services; facility should confirm coverage approval on file for elective services

Out-of-network services prior auth

RequirementOut-of-network services recommended/directed by a network physician still require prior authorization when the member's plan has out-of-network benefits

Contract noteProvider agreements may restrict directing members outside the plan service area

Financial noteMembers may incur higher out-of-pocket costs or have no coverage for out-of-network care

Prosthetics (cost threshold > $1,000)

ThresholdProsthetics prior authorization required only when retail purchase or cumulative rental cost exceeds $1,000

L-code listingNumerous prosthetic L-codes are enumerated (see prosthetics section for full list)

Provider actionObtain PA before ordering prosthetic items exceeding the $1,000 threshold

Physical/occupational/speech therapy referral

Initial referralInitial referral for physical/occupational therapy valid for up to 8 visits per condition within 6 months

If unspecifiedReferral without a specified number of visits is valid for only one visit

Submission limitationPA requests for therapy-related services cannot be submitted online; follow therapy PA submission instructions

Prior authorization required

PA statusPrior authorization is required for many listed surgical and implantable device CPT/HCPCS codes (PA required for all states)

Site-of-service reviewSite-of-service will be reviewed as part of PA for specified codes except in exempt states/territories

Exempt statesExempt: AK, MA, PR, RI, TX, UT, VI, WI

Spinal cord stimulator PA

Spinal cord stimulator PASpinal cord stimulators implanted for pain management require prior authorization for all states (specific CPT/HCPCS and L-codes listed)

Representative codesExamples include CPT 63650, 63655, 63662, 63664, 63685, 63688 and HCPCS/L-codes L8679, L8680, L8682–L8688

Site-of-serviceSite-of-service will be reviewed as part of PA for certain related codes except in exempt states