Coverage Criteria and Code-Level Prior Authorization Rules — Exceptions & Authorization Instructions
Prior authorization exceptions, conditional requirements, and authorization instructions. Consolidated guidance for services that may be exempt from prior authorization, services requiring conditional prior authorization, and how to request authorization or notifications.
Prior authorization exceptions and conditional requirements (consolidated):
- Certain diagnosis codes are expressly exempt from prior authorization when submitted with associated services. Examples include a large range of vascular, musculoskeletal, infectious, congenital and enteral/neonatal diagnosis codes (e.g., many I70.*, M86.*, L03.*, Q27.*, Q87.*, S35.*, T82.*, I73.* and related codes). Providers should verify member-specific applicability at time of service.
- Durable medical equipment (DME) items with HCPCS/K-codes listed (for example K0859, K0863, T5999, V5271, V5283, V5290 and many L-series orthotics/prosthetics codes) may be exempt from prior authorization when criteria are met; PA is required only for DME items listed as requiring prior authorization or when retail/cumulative rental cost thresholds are exceeded.
- Enteral and in-home nutritional therapy products and related HCPCS/B-codes (for example B4034–B4161 series, B4150–B4155, B4158–B4161, B9998) have mixed PA rules: many enteral supplies are not subject to PA, while certain products or those exceeding cost thresholds require prior authorization.
- EEG and ambulatory electroencephalogram: outpatient routine EEG services generally do NOT require prior authorization; inpatient long-term video EEG and certain inpatient cerebral seizure monitoring codes (e.g., 95700, 95711–95718, 95720–95726, 95724–95726) require prior authorization for inpatient use.
- Injectable medications: many high-cost and specialty injectable drugs require prior authorization (extensive list included in policy: examples include J-codes such as J1442, J2506, J1434, J1439, J1306, J3399, J2350, J9312 and numerous others). Some specific products may be handled through the pharmacy benefit (Optum Rx) and require PA via the pharmacy prior authorization line (e.g., Cimzia, Synagis, Xolair through Optum Rx). Review the policy's injectable medications list and the Review at Launch/New-to-Market procedures for up-to-date inclusions/exemptions.
- Genetic and molecular testing: many genetic/molecular CPT and G/U-codes (multiple 8xxxx, 0xxxx and U-codes listed in the policy) require prior authorization; others on the list are noted as not requiring PA. Providers must confirm by code.
- Imaging and advanced procedures: Certain advanced outpatient imaging (specific CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) require PA for participating physicians. Focused radiation therapies (proton therapy codes 77520, 77522, 77523, 77525 and associated codes 77331, 77370, 77399, 77470) require PA. Standard radiation therapy (e.g., 77402, 77407, 77412) requires PA only when billed with specified cancer diagnosis code ranges or particular revenue codes.
- Transplants and CAR T-cell therapies (including named products such as Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, Tecartus, Zynteglo, etc.) require prior authorization and case coordination through the Optum transplant team; providers must call the Optum transplant team at 888-936-7246 or follow the notification number on the member ID card.
- Ventricular assist devices (VAD), certain unclassified or miscellaneous codes (e.g., C9399, J3490, J3590 when used for specific high-cost therapies) and many other high-cost device/procedure categories require prior authorization and case management involvement.
- Experimental / investigational services and codes (examples shown: 33477, 36514, 64722, 65765, 65767, 66180, 0191T, A4638, A6000, A9274, E0231, E1831, S0810, S1030, S1031, S9988, S9990, S9991) require prior authorization and are subject to medical review.
- Joint replacement, hysterectomy, orthognathic surgery, cochlear implants, home health outpatient settings and other procedure groups listed in the policy require prior authorization per service-specific rules.
Operational notes regarding exceptions:
- Many lists include items marked as 'not required' only when submitted with certain diagnosis codes or when billed under specific HCPCS/CPT codes; PA status may change based on diagnosis, place of service (inpatient vs outpatient), and whether the drug is billed under medical benefit (J-/Q-/C-codes) or pharmacy benefit. Always validate per-member plan.
- For injectable drugs administered in outpatient settings for cancer diagnoses (chemotherapy, colony-stimulating factors, bone-modifying agents), prior authorization is required for many J- and Q-codes (e.g., Filgrastim J1442, Pegfilgrastim J2506/Q5122/Q5120, Sargramostim J2820, Denosumab J0897).
Authorization instructions (how to request prior authorization or notification):
- Submit prior authorization requests online through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal when available for the service.
- For outpatient therapy evaluation/re-evaluation codes, requests must be submitted by a primary care provider; follow the portal or OptumHealth Physical Health phone instructions when specified.
- For certain outpatient therapy and imaging codes, call OptumHealth Physical Health at 800-873-4575 or the notification number on the back of the member's health plan ID card as directed in the policy.
- For injectable medications that are covered under the pharmacy benefit (e.g., Cimzia, Synagis, Xolair), obtain prior authorization through Optum Rx Prior Authorization Line at 800-310-6826.
- For transplant and CAR T-cell therapies (and related cellular therapies), call the Optum transplant team at 888-936-7246 or use the notification number on the member's ID card; follow any fax instructions and submit the transplant/CAR T-case forms provided by the transplant team.
- For unlisted or miscellaneous high-cost codes (e.g., C9399, J3490, J3590 used for specialty therapies or novel gene/cell therapies), call the notification number on the back of the member's ID card and fax required forms to the Optum VAD/Case Management team or the team noted for that service.
- Pre-determination is highly recommended for new-to-market medications on the Review at Launch Medication List; check the policy and the Review at Launch list prior to service or ordering.
- Provide all relevant clinical documentation with the PA request: diagnosis, recent relevant testing, prior therapies and responses, site of service, and any specialty program referrals (transplant, VAD, CAR T, complex case management).
- When prior authorization is required only for inpatient services, ensure that inpatient PA is obtained; conversely, outpatient PA requirements are noted where applicable (e.g., home health outpatient, inpatient video EEG).
- If a service or code is not listed or the PA status is unclear, contact the payer's provider contact line (use the number on the member's ID card) or submit a pre-determination request to confirm PA requirements before rendering service.