CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for UnitedHealthcare

Lists services, CPT/HCPCS/ICD-10 codes, and submission instructions for prior authorization for participating UnitedHealthcare commercial plan providers; governs inpatient and outpatient services and applies to participating providers and patients covered by UnitedHealthcare plans (see plan-level exceptions).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun. 1, 2025

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jun. 1, 2025Effective date shown

>=50Codes enumerated

24/7Chat support

Portal/phoneSubmission channels

SOS appliesSite-of-service rule

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Coverage Criteria and Authorization Requirements

inv-01: Bariatric surgery coverage rules

Bariatric surgery and certain obesity-related services

Prior authorization is required for bariatric surgery and specified obesity-related services (see enumerated CPT/HCPCS codes).

Coverage conditions

Care must meet plan terms and medical necessity review.
Some plans require treatment at a designated Center of Excellence for coverage.

Some benefit plans may exclude coverage for bariatric surgery or related services in certain situations; verify plan benefits.

inv-02: Oncology supportive care

Cancer supportive care injectables

Prior authorization is required for colony-stimulating factors and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.

Also requires prior authorization

Specific J/Q codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require prior authorization when used for non-oncology diagnoses.

Examples

Anti-emetics that require prior authorization include Akynzeo (J1454, J2469), Cinvanti (J0185), Emend (J1453, J1456), Sustol (J1627).
Bone-modifying/supportive agents and ESAs that require prior authorization include Denosumab (J0897), Epoetin alfa (J0885), Eflapegrastim (J1449), Filgrastim (J1442), Filgrastim-aafi (Q5110).

Submit prior authorization requests per UnitedHealthcare instructions (see Specialty Pharmacy/Provider Portal guidance).

inv-03: Breast reconstruction prior authorization

Breast reconstruction (non-mastectomy)

Prior authorization is required for non-mastectomy breast reconstruction procedures (enumerated CPT/HCPCS codes).

Exceptions

Notification/prior authorization is not required when the procedure is billed with specified diagnosis codes (listed ICD-10 codes such as C50.* and related codes).

inv-04: Prior authorization required items (partial)

Listed items require prior authorization as indicated:

Anti-emetics

Akynzeo (palonosetron/fosnetupitant) — J1454, J2469
Cinvanti (aprepitant) — J0185
Emend (fosaprepitant) — J1453, J1456
Sustol (granisetron ER) — J1627

Bone-modifying / supportive agents

Denosumab (Prolia, Xgeva) — J0897

inv-05: Chemotherapy injectable drugs

Injectable chemotherapy and selected injectable drugs

Prior authorization is required for outpatient-administered injectable chemotherapy drugs (J9000–J9999) and specified adjunct injectable codes (e.g., J0640, J0641, J0642, J1932, J1950, J1952).

Submit requests via the UnitedHealthcare Prior Authorization and Notification tool per provider guidance.

inv-06: Continuous Glucose Monitor

Continuous glucose monitors (CGMs)

Prior authorization is required for continuous glucose monitors when used with a type 2 diabetes diagnosis.

Applicable HCPCS codes

A4226
A4238
A4239
A9276
A9277

inv-07: Cosmetic and reconstructive procedures

Cosmetic and reconstructive procedures

Prior authorization is required for cosmetic and reconstructive procedures in all states for the enumerated CPT/HCPCS codes (long list provided in the policy).

Site-of-service may be reviewed as part of the prior authorization process for specified codes; some state exceptions apply.

inv-08: Congenital heart disease services

Congenital heart disease-related services

Advance notification is required for congenital heart disease-related services, including pretreatment evaluation.

For advance notification, providers should call 888-936-7246 or the notification number on the member's ID card.

inv-09: Clinical trials

Clinical trials-related services

Prior authorization is required for services related to clinical trials billed with codes S9988, S9990, S9991.

Clinical trials are defined as rigorously controlled studies subject to institutional oversight.

inv-10: Authorization and notification criteria for listed codes

Prior authorization or notification is required as follows for the enumerated codes and items.

Prior authorization is required for the listed CPT/HCPCS procedure codes; site-of-service review will be conducted for certain codes except in specified jurisdictions.

Notification/prior authorization is required for listed DME codes when retail purchase or cumulative rental cost exceeds $1,000; some compressors require authorization regardless of cost; prosthetics are not subject to DME rules.

Advance notification is required when referring members to out-of-network ESRD dialysis providers; call 877-842-3210 for notification/prior authorization.

Diagnosis exceptions

Certain diagnosis (ICD-10) codes are listed as exceptions or mappings for specific services; consult the enumerated diagnosis codes in the policy.

inv-11: Colonoscopy screening (SOS rules)

Colonoscopy - Screening only

Screening colonoscopy codes G0105 and G0121 are subject to site-of-service prior authorization/notification; Site of Service (SOS) rules may apply.

Submit prior authorization requests via the Provider Portal or call 866-889-8054 as specified for Gastroenterology Endoscopy Advance Notification.

inv-12: Gender dysphoria treatment prior auth

Gender dysphoria treatment

Notification or prior authorization is required for gender dysphoria treatment procedures when submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9.

Examples of covered procedure codes that may require authorization when billed with F64.x

Examples include CPT codes 55970, 55980, 14000, 14001, 14041, 15734, 19303, among others listed in the policy.

Verify plan-specific requirements and submit prior authorization per Provider Portal instructions.

inv-13: Genetic/molecular testing prior auth

Genetic and molecular testing (including BRCA)

Prior authorization is required for genetic and molecular testing (including BRCA testing) performed in an outpatient setting.

Providers must notify the laboratory and UnitedHealthcare per the policy instructions; numerous CPT/HCPCS/proprietary test codes are enumerated (examples: 81162, 81228, 81400, 81479, 81521).

inv-14: Other procedural prior auth requirements

Hysterectomy, home health, infertility

Procedures requiring prior authorization

Prior authorization required for inpatient vaginal hysterectomies (e.g., 58267, 58270, 58292, 58294).
Prior authorization required for inpatient and outpatient hysterectomy and related laparoscopic/infertility procedures (examples enumerated in the policy).

Prior authorization is required for home health non-nutritional services (T1000, T1002, T1003) when performed in outpatient/home settings.

Infertility diagnostic and treatment services require prior authorization; consult the listed CPT/HCPCS and diagnosis guidance in the policy.

inv-15: Prior authorization criteria

Authorization requirement summary and diagnosis-dependent rules

Some CPT/HCPCS codes require prior authorization only when specific diagnosis (DX) codes are present; review diagnosis-dependent entries in the policy.

Screening colonoscopy CPT/HCPCS codes are subject to site-of-service rules and may require prior authorization per the SOS guidance.

Many injectable medications (enumerated J-codes and related products) require prior authorization and should be submitted via the Specialty Pharmacy Transactions tile on UHCProvider.com or per pharmacy instructions.

inv-16: Prior authorization codes and SOS notes (fragment)

Fragment lists prior-authorization requirements tied to screening colonoscopy SOS and many injectable medication HCPCS/J-codes; specific clinical criteria are not present in this fragment.

This excerpt identifies HCPCS/J-codes (e.g., J0567, J1203, J3385, J0885) referenced for prior authorization in the screening colonoscopy and injectable medication fragments; consult full policy for clinical criteria.

inv-17: Prior authorization and notification criteria (excerpt)

Services requiring prior authorization and subject to medical necessity and plan terms:

Prior authorization and notification of admission date are required for listed post-acute inpatient facilities and services (see enumerated facility types and CPT/HCPCS codes).

MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid (CPT 0071T, 0072T) is covered for certain plans but requires prior authorization as listed.

Non-emergency air transport (A0430, A0431, A0435, A0436, S9960, S9961) requires prior authorization.

Potentially unproven/experimental/investigational services listed require prior authorization and will be reviewed for medical necessity.

Unclassified/temporary codes (C9399, J3490, J3590) require notification/prior authorization only for specified products; follow Review at Launch guidance.

inv-18: Radiation therapy

Radiation therapy prior authorization conditions (partial):

Prior authorization is required for IGRT (e.g., 77014, G6017), certain IMRT codes (77385, 77386, G6015, G6016) and other listed radiation therapy services.

Standard radiation therapy (2D/3D) prior authorization is required only when obtained with diagnosis codes in specified cancer-related ranges (examples include C34.xx, C50.xx, C61, C79.51–C79.52, etc.).

inv-19: Prosthetics

Prosthetics prior authorization summary (partial):

Prior authorization is required only for the listed prosthetic HCPCS codes when retail purchase or cumulative rental cost exceeds $1,000.

Examples

Example prosthetic codes listed include L5010 and L5050 among others; verify cost thresholds in the policy.

Prosthetics are not treated as DME; separate authorization rules apply.

inv-20: Rhinoplasty

Rhinoplasty prior authorization (partial):

Prior authorization is required for rhinoplasty for participating physicians (enumerated CPT codes such as 30410, 30420, 30430); submit requests via the Provider Portal or call 866-889-8054.

Prior authorization process and submission instructions are provided in the policy for advanced outpatient imaging and related procedures.

inv-21: Pregnancy notification

Pregnancy notification (informational):

Voluntary notification is requested upon confirmation of pregnancy for numerous listed ICD-10-CM codes; notification does not imply coverage and should be made once per pregnancy.

Examples of codes

Examples of referenced pregnancy-related codes include O30.013, O30.031, O30.032, Z33.1, Z34.00–Z34.93, among others listed in the policy.

Providers should follow the policy's submission instructions for voluntary pregnancy notification.

inv-22: Site-of-service prior authorization criteria

Prior authorization requirements vary by procedure and site of service.

When a listed procedure is performed in an outpatient hospital or ambulatory surgery center (ASC), prior authorization is typically required per the Site-of-Service (SOS) rule.

If the procedure is performed at a participating office provider, prior authorization is typically not required for many codes; verify specifics in the policy.

Providers should submit prior authorization requests via the Provider Portal Prior Authorization and Notification tool or call the listed phone number (e.g., 866-889-8054) per policy instructions.

inv-23: Screening colonoscopy (SOS prior auth)

Screening colonoscopy — site-of-service prior authorization applies; see listed codes and SOS entries.

Many CPT/HCPCS codes across multiple anatomic systems are enumerated in the screening colonoscopy/SOS sections and may require prior authorization when performed in an outpatient hospital or ASC per SOS rules.

Site-of-service entries and extensive CPT lists are provided in the policy; consult those lists to determine authorization requirements for specific procedures.

inv-24: Prior authorization criteria (summary from segment)

Prior authorization and site-of-service considerations

Prior authorization is required for spinal cord stimulator implantation and listed CPT/HCPCS codes; these are subject to site-of-service review as indicated in the policy.

Laboratory-assisted sleep studies (polysomnography) require prior authorization; home sleep studies are excluded.

Numerous spinal surgery CPT codes require prior authorization for all states; site-of-service will be reviewed as part of prior authorization with specified jurisdiction exceptions.

Process notes

For therapeutic radiopharmaceuticals and certain transplant/cellular therapies, follow the policy submission instructions and special phone contacts as provided.

Site-of-service will be reviewed for many codes except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

inv-25: Prior authorization criteria (section highlights)

Prior authorization stance for listed procedures and devices in this section.

Prior authorization is required for the listed CPT/HCPCS codes and services in this section (examples include spinal surgery codes, stimulators, vein procedures, VADs, transplants, therapeutic radiopharmaceuticals).

Site-of-service exception

Site-of-service will be reviewed as part of the prior authorization process except in specified states/territories (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin).

For certain cellular and gene therapies and listed transplant products, providers should call the special prior authorization/notification phone number (e.g., 888-936-7246) per the policy.

Notes

Some codes only require prior authorization for specific diagnoses (e.g., oncology); consult the policy for diagnosis-dependent entries.

CPT/HCPCS/ICD-10 Codes and Coding Notes

Orthopedics - arthroplasty/arthroscopyCPT

23470	Arthroplasty CPT code listed as prior auth required
29826	Arthroscopy CPT code requiring prior authorization

Bariatric surgeryCPT

43644	Bariatric surgery CPT code listed as prior auth required
43770	Bariatric surgery CPT code listed as prior auth required

Breast reconstruction and related diagnosesmixed

19328	Breast reconstruction CPT code listed; prior auth required except specified diagnoses
L8600	Breast prosthesis HCPCS code listed

Oncology supportive drugs (antiemetics, ESAs)HCPCS

J1454	Akynzeo (palonosetron/fosnetupitant) - antiemetic requiring prior auth
J1627	Sustol (granisetron ER) - antiemetic requiring prior auth
J0885	Epoetin alfa - ESA requiring prior auth

Anti-emetic injectable HCPCS/J-codesHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J2469	Akynzeo (palonosetron/fosnetupitant) alternate
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1456	Emend (fosaprepitant) alternate
J1627	Sustol (granisetron extended release)

Bone-modifying / ESA / colony-stimulating agent HCPCS/J/Q-codesHCPCSCovered

J0897	Denosumab (Prolia, Xgeva)
J0885	Epoetin alfa
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)

EEG / monitoring CPT codesCPTCovered

95700	Inpatient video EEG monitoring
95711	Inpatient video EEG monitoring
95712	Inpatient video EEG monitoring
95713	Inpatient video EEG monitoring
95714	EEG monitoring
95715	EEG monitoring
95716	EEG monitoring
95718	EEG monitoring
95720	Outpatient EEG
95722	Outpatient EEG

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Injectable chemotherapy J-code groupHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin alternate
J1950	Leuprolide acetate
J1952	Leuprolide

Examples of HCPCS/CPT code groups requiring prior authorizationmixedCovered

J9000-J9999	Chemotherapy injectable drugs range
A4226	CGM supplies
95700-95726	EEG and seizure monitoring CPT codes (selected)

Clinical trial service codesHCPCSCovered

S9988	Clinical trials-related service
S9990	Clinical trials-related service

Referenced ICD-10 diagnosis codes (exceptions/mappings)ICD-10

C43.0 - C44.* / multiple mappings

ICD-10 diagnosis codes listed in series/mappings related to skin malignancy and other neoplasms; appear as exceptions or referenced diagnosis codes

HCPCS/DME codesHCPCS

A7025 - K0891 (selected HCPCS listed)

Range of HCPCS DME and supply codes enumerated in this segment that require prior authorization or notification per rules

Colonoscopy screening codesHCPCSCovered

G0105	Colonoscopy - Screening only (specific screening codes listed)
G0121	Colonoscopy - Screening only (specific screening codes listed)

Genetic and molecular testing codesCPTCovered

81162	BRCA/genetic testing — example listed
81479	Genetic test codes (representative list)

Screening colonoscopy and related SOS codesCPT | HCPCS | mixedCovered

89335
89337
89342
89343
89344
89346
89352
89353
89354
89356

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Selected J-codes appearing in fragmentHCPCS

J1411
J1412
J1413
J1414
J3398
J3399
J3401
J7170
J7175
J7185

Additional injectable and vaccine-related codesmixed

90283
90284
J1459
J1551
J1555
J1561

Selected HCPCS/J-codes from excerptHCPCS

J2323	Listed as CPT/HCPCS code requiring prior authorization in the colonoscopy/screening block
J1442	Example injectable HCPCS codes referenced
J1305	Example J-code referenced in list

MRgFUS CPT codesCPTCovered

0071T	MRgFUS procedure code
0072T	MRgFUS procedure code

Orthotics codes with cost-threshold prior authorizationHCPCSExperimental

L0220	Orthotic supply code (example)
L3900	Orthotic code (example)

Sample ICD-10-CM pregnancy codes referencedICD-10

O09.00	Pregnancy related code (example listed among many mappings)
O30.011	Pregnancy episode code listed

Prosthetics HCPCS codes (partial)HCPCS

L5010	Prosthetic code listed for prior authorization consideration
L5050	Prosthetic code listed for prior authorization consideration

Radiation therapy CPT/HCPCS codes (partial)mixed

77014	IGRT code listed under radiation therapy
77385	IMRT code listed under radiation therapy

Sample CPT codes from SOS/prior auth listCPT

57425	Colonoscopy-related CPT listed in section
64721	Carpal tunnel surgery (example code repeated)
66984	Cataract surgery code appearing in list

Excerpted CPT/HCPCS codes (partial list)CPT | HCPCS

28295	Listed CPT code present in document fragment
38221	Listed CPT code present in document fragment
38222	Listed CPT code present in document fragment
38500	Listed CPT code present in document fragment
38505	Listed CPT code present in document fragment
38510	Listed CPT code present in document fragment
38520	Listed CPT code present in document fragment
38525	Listed CPT code present in document fragment
38740	Listed CPT code present in document fragment
38760	Listed CPT code present in document fragment

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Spinal cord stimulator codes requiring prior authorizationCPT | HCPCSCovered

63650	Spinal cord stimulator implantation
63655	Spinal cord stimulator revision or removal
63685	Insertion or replacement of spinal neurostimulator pulse generator
L8679	Spinal cord neurostimulator lead, nonactive, each
L8685	Spinal cord neurostimulator external trial system

Sleep study CPT codesCPTCovered

95805	Polysomnography; sleep staging with 4 or more parameters
95807	Polysomnography with initiation of continuous positive airway pressure
95808	Polysomnography with initiation of bilevel pressure support
95810	Polysomnography for multiple sleep latency test

Spinal surgery CPT codes (partial list)CPTCovered

63042	Laminectomy, various spinal surgery codes listed in segment
63250	Spinal fusion/other spinal surgery codes (examples from list)

Spinal surgery CPT codes (partial list)CPTCovered

63265	Spinal surgery procedure code listed in section
63266	Spinal surgery procedure code listed in section
63267	Spinal surgery procedure code listed in section

Transplant CPT codes (examples)CPTCovered

33944	Heart transplant related CPT code listed
33930	Heart/lung transplant code listed

Therapeutic radiopharmaceutical HCPCS codesHCPCSCovered

A9513	Therapeutic radiopharmaceutical
A9607	Therapeutic radiopharmaceutical

Site-of-service review — exceptions

States/territories exceptedAlaska; Massachusetts; Puerto Rico; Rhode Island; Texas; Utah; the Virgin Islands; Wisconsin

Provider Submission Instructions and Actionable Notices

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with your One Healthcare ID and password, select the Prior Authorization and Notification tab, and follow the prompts. If you need help, use the portal chat (available 24/7) or call the phone numbers noted for specific services in this section. Prior authorization is not required for emergency or urgent care.

Online: Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID required).
Chat: 24/7 via the Provider Portal Contact Us page.
See service-specific phone numbers in this section (e.g., 866-889-8054, 888-397-8129, 877-842-3210, 888-936-7246).

Prior Authorization

Site-of-service review for select arthroscopy codes

Site-of-service review required as part of prior authorization for select arthroscopy and related surgical codes. The review applies when services are requested in an outpatient hospital setting or ambulatory surgery center (ASC); office or other lower-cost settings may be preferred. Exceptions apply for providers in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

Definitions and Key Terms

Definition — Prior authorization

DefinitionA review requirement for certain services that must be obtained before non-emergent care is provided; not required for emergency or urgent care.

Submission channelsPrior authorization requests may be submitted via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone, or via 24/7 chat as noted in the document

PurposeEnsures services meet plan requirements and medical necessity prior to service delivery

Definition — Center of Excellence (Bariatric)

DefinitionCenter of Excellence requirement: Some plans may require bariatric surgery to be performed at a designated Center of Excellence for coverage

ContextReferenced in bariatric surgery coverage rules; plan-level variations may apply

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun. 1, 2025

Next Review DateN/A

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

SourceLink

On This Page

Epoetin alfa — J0885

Eflapegrastim (Rolvedon) — J1449

Filgrastim (Neupogen) — J1442

Filgrastim-aafi (Nivestym) — Q5110

EEG and monitoring

Inpatient video EEG monitoring requires prior authorization — e.g., 95700, 95711, 95712, 95713
EEG monitoring series (95714–95718) prior authorization per inpatient indication; outpatient EEG (95720–95726) does not require prior authorization for outpatient hospital or ASC.

Follow UnitedHealthcare prior authorization submission instructions (Provider Portal).

Follow submission and specialty pharmacy instructions in the policy (Provider Portal / Specialty Pharmacy Transactions tile) for injectable medications and other listed items.

Follow the policy's submission channels (Provider Portal, phone, Specialty Pharmacy) and the listed code-specific instructions when requesting prior authorization.

ApplicationThese jurisdictions are exceptions to site-of-service review performed as part of prior authorization for listed codes

Supporting noteSite-of-service review is performed as part of prior authorization for many codes except in the listed states/territories

Continuous glucose monitor (CGM) diagnosis requirement

RequirementPrior authorization is required when a continuous glucose monitor (CGM) is used with a type 2 diabetes diagnosis

Example HCPCS codesA4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103

ContextDocument explicitly notes prior authorization required with type 2 diabetes diagnosis

DME cumulative rental / purchase cost threshold

ThresholdRetail purchase or cumulative rental cost greater than $1,000

ApplicationNotification/prior authorization required only for DME codes listed when purchase or cumulative rental cost exceeds the threshold

ExceptionSome compressors and specific items may require prior authorization regardless of cost; prosthetics are not treated as DME for this rule

Gender dysphoria diagnosis trigger for prior authorization

Trigger diagnosis codesF64.0, F64.1, F64.2, F64.8, F64.9

RequirementNotification or prior authorization required for gender dysphoria treatment procedures submitted with the listed diagnosis codes

Example procedure codes referenced55970, 55980, 14000, 14001, 14041, 15734, 19303 (among others)

Setting requirement for genetic and molecular testing

Setting requirementPrior authorization is required for genetic and molecular testing performed in an outpatient setting

ExamplesBRCA and other genetic tests (example CPT: 81162; other genetic panels listed) — providers must notify the laboratory and UnitedHealthcare

Submission noteProviders should follow outpatient prior authorization instructions per the Provider Portal guidance

Orthotics prior authorization cost threshold

Orthotics thresholdRetail purchase or cumulative rental cost greater than $1,000 requires prior authorization

ScopeApplies only to orthotics codes listed with cost above threshold (specific L-codes enumerated)

Related guidanceOrthotics are subject to site-of-service review where indicated in the document

Prosthetics prior authorization cost threshold

Prosthetics thresholdRetail purchase or cumulative rental cost greater than $1,000 requires prior authorization

ScopeApplies only to prosthetic HCPCS codes listed with purchase or cumulative rental cost above $1,000

ClarificationProsthetics are not treated as DME for the DME cost-threshold rules

Site-of-service review — summary and exceptions

General ruleSite-of-service will be reviewed as part of the prior authorization process for listed codes

ExceptionsExceptions to SOS review are: Alaska; Massachusetts; Puerto Rico; Rhode Island; Texas; Utah; the Virgin Islands; Wisconsin

ImplicationPrior authorization and SOS review apply for many CPT/HCPCS codes unless performed in an exempt jurisdiction

Phone contact for transplant and complex/cellular/gene therapies

Phone contactCall 888-936-7246 or the notification number on the member's ID card to initiate prior authorization/notification for listed cellular and gene therapies and transplants

ScopeApplies to specified cellular and gene therapies, certain CAR-T/autologous products, and transplant-related services

Submission follow-upProviders may be instructed to fax additional forms (e.g., VAD fax to Optum VAD Case Management) after initial call

Arthroscopy codes subject to site-of-service review include: 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828.
Site-of-service prior authorization required if performed in an outpatient hospital setting or ASC.
Providers in listed exception states/territories are not subject to the SOS review for these codes.

Prior Authorization

Clinical trials prior authorization

Prior authorization is required for services related to participation in clinical trials billed with specific trial-related codes. Ensure a prior authorization is obtained before delivering trial-related services to avoid claim denials.

Clinical trial codes requiring prior authorization: S9988, S9990, S9991.

Prior Authorization

EEG and seizure monitoring prior authorization

Inpatient video EEG (continuous seizure monitoring) requires prior authorization. Routine outpatient EEGs do not require prior authorization, although place-of-service rules apply for some monitoring services.

Inpatient video EEG / cerebral seizure monitoring CPT codes: 95700, 95711–95716, 95718.
Outpatient EEG CPT codes (no prior authorization required): 95720, 95722, 95724, 95726.

Prior Authorization

ESRD dialysis notification

Advance notification is required when referring members to an out-of-network provider for end-stage renal disease (ESRD) dialysis services. Contact the plan for notification or prior authorization before arranging out-of-network dialysis to avoid coverage issues.

For notification/prior authorization for ESRD dialysis, call: 877-842-3210.
Prior authorization is not required for ESRD when a member receives dialysis within the UnitedHealthcare network; advance notification is required when referring outside the network.

Prior Authorization

Diagnosis-dependent prior authorization

Some codes require prior authorization only when submitted with specific diagnosis codes (diagnosis-dependent prior authorization). Verify both the CPT/HCPCS and the ICD-10 diagnosis on the submission to determine if authorization is required.

Example: Certain cosmetic/reconstructive and screening codes may be exempt from prior authorization when billed with listed diagnosis codes (see code list in relevant sections).
Check the policy details for codes flagged as "prior authorization required only with specific DX" before submitting.

Prior Authorization

Out-of-network referral prior authorization

Referrals or recommendations to out-of-network providers may be subject to plan restrictions and prior authorization. Sending members to non-contracted providers can increase member out-of-pocket costs or result in no coverage; obtain prior authorization when required by the plan.

Out-of-network referral prior authorization may be required depending on the provider agreement and the service requested.
Verify network status and authorization requirements before directing members to non-contracted providers.

Prior Authorization

Prosthetics prior authorization threshold

Prior authorization is required for prosthetic items when the retail purchase price or cumulative rental cost exceeds $1,000 for the listed HCPCS codes. Confirm cost thresholds and obtain authorization for high-cost prosthetics prior to delivery.

Examples of prosthetic HCPCS codes subject to the $1,000 threshold: L5010, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5230, L5250, L5270, L5280, L5301, L5321, L5331.
Only the prosthetic codes listed in the policy are subject to the purchase/rental cost threshold.

Note

Pregnancy voluntary notification

Voluntary pregnancy notification is requested when pregnancy is confirmed. Providers are asked to notify the plan to coordinate care and benefits; numerous pregnancy-related ICD-10 codes are listed for reporting.

Recommended ICD-10-CM pregnancy and prenatal codes include (examples): Z33.1, Z34.xx series, Z36, O30.xx series, O99.280, O99.89, Z32.01.
Notification is voluntary but helps with care coordination and member support services.

Prior Authorization

Site-of-service prior authorization rule

Site-of-service prior authorization rules apply broadly: certain procedures require prior authorization when performed in an outpatient hospital or ASC setting; the plan may prefer office or other lower-cost sites of service. Review the site-of-service notes for each procedure to determine authorization needs and exceptions.

Office-based program: prior authorization required if the service is requested in an outpatient hospital or ASC; participating provider office may be preferred.
Exceptions: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin are exempt from some SOS reviews—check specific code entries.

Prior Authorization

VAD prior authorization and notification

Ventricular assist devices (VADs) require prior authorization and notification. Providers must call the notification number on the member's ID card and follow instructions from the Optum VAD Case Management Team, including faxing the required form provided by the nurse.

Call the notification number on the member's ID card before arranging VAD services.
Fax the completed form provided by the nurse to the Optum VAD Case Management Team as instructed.
Common VAD-related CPT codes: 33927, 33928, 33929, 33975–33983 (see policy for full list).

Prior Authorization

Vein procedures prior authorization

Vein procedures (removal and ablation of saphenous veins and named branches) require prior authorization. Obtain authorization before performing endovenous ablation, phlebectomy, or related vein interventions to ensure coverage.

Vein procedure CPT codes requiring prior authorization include: 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 37243, 37700, 37718, 37722, 37780 (see policy for full list).
Prior authorization helps confirm medical necessity for treatment of venous disease and varicose veins.

ImplicationProviders should verify plan-specific Center of Excellence requirements before scheduling

Definition — Prior authorization submission

DefinitionPrior authorization submission: the methods by which providers submit requests (Provider Portal Prior Authorization and Notification tool, telephone numbers, and 24/7 chat)

Portal detailLog in at UHCprovider.com using One Healthcare ID and select the Prior Authorization and Notification tab

Phone alternativesDocument lists phone numbers (e.g., 888-397-8129; 866-889-8054) as alternate submission channels

Definition — Clinical trials

DefinitionClinical trials: a rigorously controlled study of a new drug, medical device or other; services related to clinical trials require prior authorization

Example codesS9988, S9990, S9991 listed for clinical trial–related services

ImplicationClinical trial services billed with the listed codes require prior authorization per the document

Definition — Cochlear and other auditory implants

DefinitionCochlear and other auditory implants: devices with internal and external components to assist persons with profound sensorineural deafness; prior authorization required

Example codesProcedure and device examples: 69710, 69714, 69930; L8619, L8690, L8691, L8692, L8614

ActionProviders must obtain prior authorization for cochlear and auditory implant services

Definition — Site-of-service review

DefinitionSite-of-service review: a review conducted as part of prior authorization to determine the appropriate setting for the procedure (e.g., outpatient hospital vs participating office)

EffectMany CPT/HCPCS codes require prior authorization only when performed in an outpatient hospital or ASC; not required when performed at a participating office provider in many cases

ExceptionsSite-of-service review is not performed in specific jurisdictions (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands, Wisconsin)

Definition — Advance notification

DefinitionAdvance notification: required notice (often by phone) for certain services — e.g., when referring members to out-of-network ESRD dialysis providers

Example actionFor ESRD dialysis advance notification/prior authorization call 877-842-3210

ScopeAdvance notification may be required in lieu of or in addition to prior authorization for select services

Definition — Site of Service (SOS)

DefinitionSite of Service (SOS): designation indicating the setting where a service is performed (e.g., outpatient hospital, ASC, participating office) and used to determine whether prior authorization applies

ApplicationSOS rules may require prior authorization for certain codes when performed in outpatient hospital or ASC settings

Example codesG0105, G0121 listed in colonoscopy screening section with SOS applicability

Definition — Genetic and molecular testing (BRCA)

DefinitionGenetic and molecular testing (including BRCA): testing performed in an outpatient setting that requires prior authorization and coordination with UnitedHealthcare and the laboratory

Example codes81162 (BRCA), 81479 and numerous other genetic panel CPT/HCPCS/U-codes listed in the document

Provider actionProviders must obtain prior authorization for outpatient genetic/molecular testing and follow laboratory notification instructions

Definition — site of service

DefinitionSite of service: the healthcare setting (office, outpatient hospital, ASC) used to determine prior authorization applicability

RulePrior authorization often required when service is in outpatient hospital/ASC; not required if performed at participating office in many cases

Related termSee Site of Service (SOS) rules for detailed code-level applicability

Definition — site of service (SOS) (note)

DefinitionSite of service (SOS) — note indicating SOS only applies for certain screening procedures (e.g., colonoscopy screening) where prior authorization depends on setting

ExampleScreening colonoscopy entries repeatedly note 'SOS only applies' for listed codes; J0567 and J1203 referenced in this fragment

ActionProviders should check SOS guidance for the specific code and setting before submitting prior authorization

Definition — Post-acute inpatient services

DefinitionPost-acute inpatient services: facilities providing post-acute care (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals) that require prior authorization/notification of admission date

ActionPrior authorization and notification of admission date required for listed post-acute inpatient facilities

ExamplesAcute inpatient rehabilitation, long-term acute care hospitals — contact per facility submission instructions

Definition — Unclassified and temporary codes (C9399, J3490, J3590)

DefinitionUnclassified and temporary codes (C9399, J3490, J3590): notification/prior authorization is required only for specified new-to-market or identified products (e.g., Nulibry™, Rivfloza™, Revcovi™)

GuidanceCheck 'Review at Launch' policy for new-to-market medications; predetermination is highly recommended for listed drugs

SubmissionFor non-oncology uses submit via Provider Portal or call the listed number as directed

Definition — Potentially unproven / experimental services

DefinitionPotentially unproven services: services considered experimental, investigational, or lacking sufficient high-quality evidence; prior authorization required and medical necessity review will be conducted

ExamplesMultiple CPT/HCPCS codes listed as potentially unproven (e.g., 26340, 33289, 33361-33366, 36514)

ImplicationProviders should expect medical necessity review and obtain prior authorization before performing these services

Definition — Voluntary pregnancy notification

DefinitionVoluntary pregnancy notification: providers are asked to notify UnitedHealthcare upon confirmation of pregnancy for specified ICD-10-CM codes; notification does not imply coverage and should be made once per pregnancy

PurposeEnables case and disease management enrollment; notification is informational only and does not change coverage

ExamplesMultiple O09.* codes listed for voluntary notification

Definition — Prosthetics prior authorization

DefinitionProsthetics prior authorization: prior authorization required only for prosthetic HCPCS codes listed when retail purchase or cumulative rental cost exceeds $1,000

ScopeApplies to prosthetic codes enumerated in the document (L5xxx examples provided)

Relation to DMEProsthetics are explicitly noted as not DME for the DME cost-threshold rules

Definition — Site of service (SOS) rule

DefinitionSite of service (SOS) rule: many CPT/HCPCS codes require prior authorization only when requested in an outpatient hospital or ASC setting; not required if performed at a participating office provider in many instances

Provider actionConfirm the service setting (office vs outpatient hospital/ASC) before submitting prior authorization to determine applicability

ExampleSOS guidance applied across multiple procedure categories in the document (colonoscopy, rhinoplasty, ENT, etc.)

Definition — Prior authorization process

DefinitionPrior authorization process: submission methods include the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, telephone numbers listed in the document, and 24/7 chat

Portal instructionsGo to UHCprovider.com, Sign In with One Healthcare ID, and select the Prior Authorization and Notification tab

Phone/chat alternativesDocument provides alternate phone numbers and 24/7 chat as additional submission channels

Definition — Site of service (SOS) (designation)

DefinitionSite of service (SOS): outpatient hospital is frequently the designated SOS for many listed procedures; SOS determines when prior authorization applies

ApplicationThe document repeatedly flags outpatient hospital as the SOS that often triggers prior authorization requirements

Provider actionVerify the SOS for the specific CPT/HCPCS code before scheduling to confirm whether prior authorization is required

Definition — Site-of-service (SOS) review

DefinitionSite-of-service (SOS) review: the review conducted during prior authorization to determine appropriateness of the requested setting; applied for many codes with specified state exceptions

ExceptionsSOS review not applied in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin

ImplicationSOS review may affect approval if service is requested in an outpatient hospital or ASC rather than a participating office

Definition — Spinal cord stimulator

DefinitionSpinal cord stimulator: an implanted device for pain management; implantation requires prior authorization for all states

Example codes63650, 63655, 63685 and related HCPCS (L8679, L8685, etc.) listed in the document

NoteSite-of-service review applies for listed stimulator codes except in specified state exceptions

Definition — Ventricular assist device (VAD)

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart; VADs require prior authorization

Contact instructionCall the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management Team as instructed

Example codes33927, 33928, 33929, 33975, 33976, 33979, 33981-33983 referenced

Definition — Stimulators (neurostimulator / bone growth stimulator)

DefinitionStimulators (neurostimulator / bone growth stimulator): implantable devices that send electrical impulses; implantation requires prior authorization for all states

ExamplesNeurostimulator and bone growth stimulator codes and HCPCS (e.g., E0748, E0749) appear in the document

Site-of-serviceSite-of-service review will be conducted as part of prior authorization for listed stimulator codes except in specified states/territories