Colorado Rocky Mountain Health Plans Prior Auth Policy

General rules

General prior authorization rules and submission methods:

Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password or call 844-284-0146.

Prior authorization is not required for emergency or urgent care.

Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services.

Drug prior authorization criteria (partial)

Drugs and agents requiring prior authorization when used in specified settings or diagnoses:

Colony-stimulating factor drugs and bone-modifying agents require prior authorization when administered in an outpatient setting for a cancer diagnosis.

Examples of injectable colony-stimulating factors that require prior authorization

J1442 (Filgrastim - Neupogen) or biosimilar codes (Q5101, Q5110, Q5120, Q5122, Q5125) as listed.
J1447 (Tbo-filgrastim), J1449 (Eflapegrastim-xnst), J2506 (Pegfilgrastim - Neulasta) as listed.

Injectable erythropoiesis-stimulating agent J0885 (Procrit) requires prior authorization.

Bone-modifying agent denosumab (Xgeva) J0897 requires prior authorization.

Certain listed colony-stimulating factor codes (J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require prior authorization for non-oncology diagnoses as noted; see injectable medications section for submission instructions.

Cardiology prior authorization

Cardiology procedures requiring prior authorization:

Participating physicians must obtain prior authorization prior to performance for outpatient and office-based diagnostic catheterizations.

Prior authorization is required prior to performance for echocardiograms and stress echocardiograms.

Electrophysiology implants require prior authorization prior to performance.

Prior authorization coverage stance

Codes and services requiring prior authorization in this document excerpt include:

Services and codes explicitly listed in the document (CPT/HCPCS/ICD-10/DME) require prior authorization when shown as 'Prior authorization required' in the lists.

Durable medical equipment (DME) items included in the lists require prior authorization; some DME entries have additional information such as cumulative rental or purchase cost thresholds.

Enteral services, surgical procedures and certain experimental/investigational codes included in the lists require prior authorization.

Prior authorization requirement for listed codes

The following codes and service categories require prior authorization as specified in the lists.

If a CPT/HCPCS/ICD-10/DME code appears in the document's listed sections, prior authorization is required (see the specific code lists for details).

Applies to categories such as DME, enteral services, genetic/molecular testing, injectable medications and select surgical procedures listed in the document.

Prior authorization requirements (excerpt)

Codes and categories that require prior authorization and special submission notes

Genetic and molecular testing codes listed (for example CPT codes and U-codes referenced) require prior authorization; submission should be made via the UnitedHealthcare Provider Portal as noted.

Many injectable medications (multiple J/Q codes listed) require prior authorization; providers should submit requests online via the UnitedHealthcare Provider Portal; some products (e.g., Cimzia, Synagis) require prior notification through Optum Rx prior notifications.

Home health care prior authorization is required only in outpatient settings, including the member's home.

Prior authorization criteria (fragment)

Prior authorization required for the following service groups and codes as listed in this fragment.

Joint replacement (total hip and knee) procedures listed (e.g., codes 24360, 24361, 24362, 24363, 24370, 24371, 27120, 27125, 27132, 27134, 27137) require prior authorization.

Occupational and physical therapy CPT codes listed require prior authorization after the initial evaluation and before the initial therapy visit, and for ongoing therapy visits.

Orthotics and prosthetics L-codes listed require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Prior Authorization Criteria (code list only)

The document identifies specific HCPCS/CPT antiemetic codes that require prior authorization. No clinical criteria or exclusions are provided in these chunks.

HCPCS/CPT antiemetic supply codes such as L0810, L0820, L0830, L0859 are listed as requiring prior authorization as shown in the code lists.

Prior authorization requirement for listed antiemetic codes

Lists HCPCS/CPT codes that require prior authorization for antiemetic products; includes an 'Additional Information' monetary note.

Antiemetic HCPCS L-codes (examples: L0810, L0820, L0830, L0859, L0710, L0700, L0640) require prior authorization as listed; multiple entries include 'Additional Information = $500.'

Prior authorization requirement for listed HCPCS L‑codes

The document identifies specific HCPCS L‑codes that require prior authorization; some entries include 'Additional Information' such as dollar values.

Selected HCPCS L-series orthotics/prosthetics codes (for example L0710, L0859, L0810, L0820, L0700, L0830, L0640, L0638) are listed as requiring prior authorization.

Many L‑code entries include 'How to obtain prior authorization' or 'Additional Information' references; providers should follow the documented prior authorization process for these L-codes.

Radiation therapy

Radiation therapy prior authorization criteria and submission instructions

Image-guided radiation therapy (IGRT), intensity-modulated radiation therapy (IMRT) and other advanced radiation modalities require prior authorization.

Standard 2D/3D radiation therapy requires prior authorization only when billed with diagnosis codes in specified cancer diagnosis ranges (for example C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92) as listed.

Submit radiation prior authorization requests online using the UnitedHealthcare Provider Portal or call 866-889-8054; health care professionals ordering advanced outpatient imaging must provide notification prior to scheduling.

Speech therapy

Speech therapy prior authorization criteria

Prior authorization is required after the initial evaluation and before the initial therapy visit, and is required for ongoing therapy visits.

This prior authorization requirement for speech therapy applies only to members aged 3 years and older.

Relevant speech therapy CPT codes listed include 92507, 92508 and 92526; obtain prior authorization prior to scheduling ongoing visits.

Orthotics/Prosthetics

Orthotics and prosthetics prior authorization list

Multiple orthotics and prosthetics L-codes listed in the document require prior authorization (selected examples are contained in the coding lists).

Prior authorization for orthotic and prosthetic items is required only when the retail purchase or cumulative rental cost exceeds $500 (see 'Additional Information').

Prior authorization requirements (fragment)

Services requiring prior authorization and contact/process instructions as listed in this fragment.

Transplant and CAR T-cell therapy services require prior authorization; contact Optum Health Transplant Resource Services at 888-805-1802 or the notification number on the member's ID card.

For ventricular assist devices (VAD) prior authorization: call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

Vein procedures (removal/ablation of main trunks and named branches of the saphenous veins) require prior authorization (examples: CPT 36473, 37718, 36475, 37722).

Stimulators, bone-growth stimulators and neurostimulators and related HCPCS/CPT codes require prior authorization as indicated in the lists (examples include 0098T, E0747, E0760, L8680 series).

Codes and Code Groups Requiring Prior Authorization

Selected procedure codes requiring prior authorization (partial list)CPTCovered

43644	Bariatric surgery procedure code listed for prior authorization
43645	Bariatric surgery procedure code listed for prior authorization
43659	Bariatric surgery procedure code listed for prior authorization
43770	Bariatric surgery procedure code listed for prior authorization
43846	Bariatric surgery procedure code listed for prior authorization
20975	Bone growth stimulator code
20979	Bone growth stimulator code
19316	Breast reconstruction (non-mastectomy) code
19330	Breast reconstruction (non-mastectomy) code
19357	Breast reconstruction (non-mastectomy) code

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Selected diagnosis (ICD-10) codes referencedICD-10

C50.022	Breast cancer diagnosis code referenced in reconstruction section
C50.119	Breast cancer diagnosis code referenced in reconstruction section
D05.00	Carcinoma in situ code referenced
Z90.10	Post-surgical status code referenced

Chemotherapy injectable codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Lupron Depot
J1954	Leuprolide acetate
J1932	Lanreotide

EEG CPT codesCPTCovered

95700	Inpatient video EEG monitoring
95711	EEG monitoring
95712	EEG monitoring
95713	EEG monitoring
95715	EEG monitoring
95716	EEG monitoring
95718	EEG monitoring

Continuous glucose monitor HCPCS codesHCPCSCovered

A4226	CGM supply
A9278	CGM supply
A4239	CGM supply
E0787	Durable medical equipment related to CGM
A9276	CGM transmitter
A9277	CGM transmitter

Skin/cutaneous diagnosis codesICD-10Covered

C44.201	Listed in section as requiring prior authorization (context: cosmetic/reconstructive coding groups)
C44.202	Listed in section as requiring prior authorization
C44.209	Listed in section as requiring prior authorization

Select DME/HCPCS examplesHCPCSCovered

A9279	DME code listed as prior authorization required
E0471	Prosthetics - prior authorization

Genetic/molecular testingCPTCovered

81162	Genetic/molecular testing code listed as prior authorization required
81403	Genetic/molecular testing code listed as prior authorization required
81407	Genetic/molecular testing code listed as prior authorization required
81412	Genetic/molecular testing code listed as prior authorization required

Sample injectable medications requiring prior authorization (many more listed)HCPCSCovered

J3262	Actemra
J0801	Acthar
J2329	Briumvi
J3247	Cosentyx
J0177	Eylea HD
J0178	Eylea
J0567	Brineura
J2326	Spinraza
J1303	Ultomiris

Genetic and molecular testing codesmixedCovered

81162	Genetic test code listed
81403	Genetic/molecular multigene panel
0037U	Molecular diagnostic U-code
0245U	Molecular diagnostic U-code

Joint replacement procedure codesCPTCovered

24360	Joint replacement related CPT code listed (excerpt)
27132	Total hip replacement CPT code listed

Prior authorization code listsmixed

24360-24363,24370-24374,27120-27137	Joint replacement related CPT codes (hip/knee) listed in fragment
97022-97039,97110-97140,97530-97535	Occupational/physical therapy CPT codes listed
L0112,L0462,L0464,L0480,L0482,L0484,L0486,L0624,L0631-L0638,L0700,L0710,L0810-L0859	HCPCS L-codes for orthotics/prosthetics listed

Antiemetic HCPCS/CPT codesHCPCS

L0810	Antiemetic related HCPCS code as listed
L0820	Antiemetic related HCPCS code as listed
L0830	Antiemetic related HCPCS code as listed
L0859	Antiemetic related HCPCS code repeatedly listed

Antiemetic HCPCS codesHCPCSCovered

L0710-L0859	HCPCS code range referenced repeatedly
L0700-L0830	HCPCS code range referenced
L0810	HCPCS code example
L0820	HCPCS code example
L0830	HCPCS code example
L0859	HCPCS code example
L0640	HCPCS code example (appears in chunk 127)

Example antiemetic HCPCS codesHCPCSCovered

L0710	HCPCS L‑series code listed repeatedly in antiemetic section
L0859	HCPCS L‑series code listed repeatedly in antiemetic section

Selected orthotics/prosthetics L-codesHCPCS | mixedCovered

L5857
L5858
L5930
L5950
L5960
L5961
L5962
L5964
L5966
L5968

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Radiation therapy and special radiation service codesCPT | HCPCS | G-codes | mixedCovered

77520
77522
77523
77331
77370
77399
77525
77470
77371
G0340

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Spinal and neurosurgical CPT codesCPTCovered

22100
22101
22102
22110
22112
22114
22206
22207
22210
22212

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Selected rhinoplasty, septoplasty, musculoskeletal and associated procedure codesCPTCovered

30400
30435
30410
30450
30465
29823
29824
30420
30460
30430

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listed codes (radiation therapy, spinal surgery, and related procedural codes)mixed

22810
22812
22818
22819
22830
22849
22850
22852
22855
22856

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transplant-related procedure codes and CAR T-cell therapy codesmixed

32850
32854
33933
33945
38212
38232
44132
44137
47133
47142

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How to Obtain Prior Authorization — Submission & Operational Steps

Prior Authorization

Submission instructions and general prior authorization rules

Submit prior authorization requests online via the UnitedHealthcare Provider Portal using One Healthcare ID (Prior Authorization and Notification tool at UHCprovider.com) or by phone at 844-284-0146. Prior authorization is not required for emergency or urgent care; out-of-network physicians, facilities and other providers must request prior authorization for all procedures and services.

Online: UHCprovider.com — sign in with One Healthcare ID and select Prior Authorization and Notification tab.
Phone: 844-284-0146.
Emergency/urgent care: no prior authorization required.
Out-of-network providers: must request prior authorization for all services.

Prior Authorization

Drug prior authorization requirements

Prior authorization is required for injectable colony‑stimulating factor drugs, erythropoiesis‑stimulating agents, and certain bone‑modifying agents when administered in an outpatient setting for a cancer diagnosis; specific HCPCS/J‑codes are listed in the document.

Examples of listed codes: J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J0885, J0897.

Prior Authorization

Cardiology prior authorization

Participating physicians must obtain prior authorization before performing outpatient and office‑based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms.

Prior Authorization

Inpatient video EEG prior authorization

Prior authorization is required for inpatient video electroencephalogram services billed with CPT codes 95700 and 95711–95718.

CPT codes: 95700, 95711, 95712, 95713, 95715, 95716, 95718.

Prior Authorization

Chemotherapy injectable drugs prior authorization

Injectable chemotherapy drugs (range J9000–J9999) and specified J‑codes (for example J0640, J0641, J0642, J1950, J1954, J1932) require prior authorization; note outpatient hospital or ambulatory surgical center administration is not required to have prior authorization per the document.

Chemotherapy J‑code range: J9000–J9999.
Examples: J0640, J0641, J0642, J1950, J1954, J1932.
Exception note: not required for outpatient hospital or ambulatory surgical center in some cases.

Prior Authorization

Cochlear implants prior authorization

Cochlear implants and related auditory device procedures and HCPCS L‑codes require prior authorization before provision.

Example CPT/HCPCS codes: 69710, 69714, 69930, L8614, L8619, L8690, L8691, L8692.

Prior Authorization

Continuous glucose monitor prior authorization

Continuous glucose monitor (CGM) HCPCS codes require prior authorization when used with a type 2 diabetes diagnosis.

Applicable HCPCS codes include A4226, A9278, A4239, E0787, A9276, A9277.

Prior Authorization

Prior authorization required for listed codes

The document lists numerous CPT/HCPCS/ICD codes and service categories that require prior authorization; providers must obtain prior authorization for services and codes as listed.

Includes repeated entries for antiemetic codes and multiple service groups (DME, enteral, surgical, genetic testing, etc.).

Prior Authorization

DME prior authorization codes and notes

Durable medical equipment (DME) codes listed in the document require prior authorization; some DME items require prior authorization only when the retail purchase or cumulative rental cost exceeds $500.

Examples of DME codes: A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471.
Cost threshold: prior authorization required when retail purchase or cumulative rental cost is more than $500 for specified items.

Prior Authorization

Enteral, surgical, experimental/investigational codes requiring prior auth

Enteral services, selected surgical CPT codes, and procedures marked experimental/investigational in the list require prior authorization; the document marks enteral services and several surgical CPT/HCPCS codes as prior authorization required.

Enteral service examples: B9002, B9998.
Experimental/investigational examples: 33477, 36514, 64722, 65765, 65767, 66180.

Prior Authorization

How to obtain prior authorization / submission channels

Submit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or via the Contact Us page; some items recommend calling or using Optum Rx prior notifications for specific drugs.

Use Prior Authorization and Notification tool on UHCprovider.com (sign in with One Healthcare ID).
Alternative: connect via the Contact Us page or call as specified for particular services.

Prior Authorization

Optum Rx prior notification instruction

For Cimzia and Synagis obtain prior notification through Optum Rx prior notifications services at 800‑310‑6826.

Prior Authorization

Prior authorization for colony-stimulating factors (non-oncology)

For colony‑stimulating factor J/Q codes used for non‑oncology diagnoses, submit prior authorization requests online using the UnitedHealthcare Provider Portal.

Codes noted include J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122.
Use UHCprovider.com Prior Authorization and Notification tool to submit.

Prior Authorization

Submission instructions

Please submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or use the Contact Us page to connect 24/7; multiple sections reiterate portal submission as the preferred method.

Portal submission repeatedly required for injectable medications and other listed services.
Contact Us page is an alternative for 24/7 access.

Prior Authorization

Joint replacement prior authorization

Joint (total hip and knee) replacement procedures require prior authorization for the CPT codes listed in the document.

Sample CPT codes listed: 24360, 24361, 24362, 24363, 24370, 24371, 27120, 27125, 27132, 27134, 27137.

Prior Authorization

Therapy prior authorization timing

Occupational and physical therapy require prior authorization after the initial evaluation and before the initial therapy visit, and prior authorization is required for ongoing therapy visits for all listed therapy codes.

Therapy CPT examples: 97022–97039 series, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97530, 97535.
Obtain prior authorization after evaluation and before beginning therapy sessions.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery for treatment of maxillofacial/jaw functional impairment requires prior authorization; note prior authorization applies only for members age 3 years and older.

Example CPT/HCPCS codes: 97750, 97799, 21121, 21141, 21123, 21142, 21147, 97760, 21125, 21143, 97761, 21127, 21145, 21151, 21146, 21154, 21193, 21155, 21198, 21208, 21240.

Prior Authorization

Orthotics/prosthetics prior authorization and threshold

Orthotics and prosthetics require prior authorization only for items with a retail purchase or cumulative rental cost exceeding $500; many L‑series HCPCS codes are listed and include directions for how to obtain prior authorization.

Cost threshold: retail purchase or cumulative rental cost > $500 triggers prior authorization.
Extensive L‑code examples appear in the document (see L0112, L0462, L0464, L0486, L0631–L0638, L0700, L0710, L0810–L0859, etc.).
Many L‑codes include 'How to obtain prior authorization' in their entries.

Prior Authorization

Prior authorization requirement for listed antiemetic codes

HCPCS/CPT antiemetic supply codes (for example L0810, L0820, L0830, L0859 and related L‑code ranges) require prior authorization; several entries note 'Additional Information = $500.' alongside these listings.

Antiemetic HCPCS examples: L0810, L0820, L0830, L0859, and broader ranges L0700–L0830, L0710–L0859.
Additional Information in multiple entries: $500.

Prior Authorization

Antiemetic codes requiring prior authorization

Multiple HCPCS L‑codes and L‑code ranges for antiemetic and related supplies require prior authorization; the document repeatedly annotates some entries with an 'Additional Information' amount of $500.

Listed L‑codes include L0710, L0700, L0640 and many others across the L‑series.
The 'Additional Information' monetary note of $500 appears with several entries.

Prior Authorization

Antiemetic HCPCS L‑codes requiring prior authorization

Extensive orthotics/prosthetics L‑codes in the document specify prior authorization and include process references ('How to obtain prior authorization') for many codes in the series.

Examples include L1000, L1005, L1200, L1310, L1700, L1830, L2030 and many additional L‑codes listed across the sections.

Prior Authorization

Orthotics/Prosthetics L‑codes and prior authorization process references

The document includes a long list of orthotics and prosthetics L‑codes that include explicit instructions or markers indicating how to obtain prior authorization; providers should follow the listed 'How to obtain prior authorization' guidance for those codes.

Large L‑code list (see document) with 'How to obtain prior authorization' noted for many entries.

Prior Authorization

Submission instructions for prior authorization

Please submit requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054 for standard radiation therapy and advanced outpatient imaging notifications; health care professionals ordering advanced outpatient imaging must provide notification prior to scheduling.

Portal submission: UHCprovider.com.
Phone for these services: 866‑889‑8054.
Ordering providers are responsible for providing notification prior to scheduling advanced outpatient imaging.

Prior Authorization

Private duty nursing prior authorization

Private duty nursing services require prior authorization; the document lists relevant HCPCS codes (T1000, T1002, T1003) that must be authorized prior to provision.

HCPCS examples: T1000, T1002, T1003.
Obtain prior authorization before providing private duty nursing services.

Prior Authorization

Potentially unproven services prior authorization

Certain potentially unproven services are designated as prior authorization required; the document lists example CPT/HCPCS codes (for example 33289, C2624) that require authorization.

Examples: 33289, C2624.
Confirm prior authorization is obtained before scheduling/providing potentially unproven services.

Prior Authorization

Radiation therapy prior authorization

Radiation therapy modalities such as image‑guided radiation therapy (IGRT), intensity‑modulated radiation therapy (IMRT) and related codes require prior authorization; standard 2D/3D radiation therapy requires prior authorization only when billed with specified cancer diagnosis code ranges.

IGRT/IMRT and associated codes (e.g., 77014, 77385, 77386, G6001, G6002, G6015) require prior authorization.
Standard 2D/3D codes require prior authorization only with diagnoses in ranges like C34.00–C34.92, C50.011–C50.929, C61, etc.

Prior Authorization

Speech therapy prior authorization

Speech therapy requires prior authorization after the initial evaluation and before the first therapy visit and for ongoing therapy visits; this requirement applies only to members age 3 years and older.

Speech therapy CPT examples: 92507, 92508, 92526.
Prior authorization timing: after evaluation and before initial therapy visit; required for ongoing visits.
Applies to members ≥ 3 years of age.

Prior Authorization

Transplant and CAR T-cell therapy prior authorization

Transplant and CAR T‑cell therapy services require prior authorization; for transplant and CAR T‑cell therapy contact Optum Health Transplant Resource Services at 888‑805‑1802 or use the notification number on the member's ID card.

Examples of listed CAR T and gene therapy codes: Q2041, Q2042, Q2053, Q2054; sample procedure and J‑codes also listed in the transplant sections.
Contact: Optum Health Transplant Resource Services 888‑805‑1802 or the notification number on back of member ID card.

Prior Authorization

Stimulators and neurostimulator prior authorization

Prior authorization is required for stimulators, bone‑growth stimulators, neurostimulators and related HCPCS codes as indicated in the document; providers must obtain authorization before implantation or provision.

Examples include bone‑growth stimulator codes and HCPCS E0747, E0748, E0749, E0760, and related neurostimulator codes.

Prior Authorization

VAD prior authorization process

For ventricular assist devices (VAD) prior authorization, call the notification number on the back of the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855‑282‑8929.

Call the notification number on the member's health plan ID card first.
Fax required form to Optum VAD Case Management at 855‑282‑8929.

Prior Authorization

Vein procedures prior authorization

Vein procedures that remove or ablate the main trunks and named branches of the saphenous veins for treatment of venous disease or varicose veins require prior authorization; the document lists example CPT codes such as 36473, 37718, 36475, 37722.

Example CPT codes: 36473, 36475, 36478, 37700, 37718, 37722, 37780.

Operational Coding Notes and Thresholds

inv-36: Cancer outpatient drug PA requirement

RequirementPrior authorization required for colony-stimulating factor drugs and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis.

Codes referencedExamples include J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125.

SettingsApplies to outpatient administration (see cancer supportive care).

inv-37: Outpatient chemotherapy prior auth exception

ExceptionOutpatient chemotherapy administered in an outpatient hospital or ambulatory surgical center does not require prior authorization.

General ruleInjectable chemotherapy drugs (J9000-J9999) and listed J-codes otherwise require prior authorization when applicable.

Source noteSee chemotherapy section for listed J-codes and site-based exception.

inv-38: DME cost threshold note

ThresholdDME items require prior authorization when retail purchase or cumulative rental cost is more than $500.

ExamplesProsthetics and specified DME codes (e.g., E0445, E0471) noted with Additional Information related to cost thresholds.

ScopeApplies only to the DME codes listed in the document sections referencing Additional Information.

inv-39: Prior authorization requirement for white blood cell colony-stimulating factors

RequirementWhite blood cell colony-stimulating factor codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non-oncology diagnoses.

Oncology noteFor oncology diagnoses, see the Cancer supportive care section for outpatient administration requirements.

Submission for non-oncology DxFor non-oncology diagnoses submit requests online using the UnitedHealthcare Provider Portal.

inv-40: Orthotics/prosthetics prior authorization cost threshold

ThresholdOrthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost exceeds $500.

CodesApplies to multiple L‑codes and related CPT/HCPCS entries listed in the orthotics/prosthetics sections (e.g., L0484, L0631, L0486).

How to obtainMany L‑codes include 'How to obtain prior authorization' references in the document.

inv-41: Additional Information Price Threshold

Amount'Additional Information' entries alongside antiemetic and related HCPCS listings specify $500.

ContextThe $500 note appears repeatedly with HCPCS antiemetic supply codes (L0810, L0820, L0830, L0859) and related entries.

Applies toUsed as a price threshold indicator in the antiemetic and prosthetics sections of the list.

inv-42: Additional Information amount

Amount specifiedAdditional Information dollar amount listed as $500 in multiple HCPCS/L‑code entries.

Associated codesAppears with L0810, L0820, L0830, L0859 and other L‑series codes in the antiemetic and orthotics sections.

RepetitionThe $500 Additional Information note is repeated across several chunks in the document.

inv-43: Standard radiation therapy prior auth diagnosis range

Diagnosis range conditionStandard 2D/3D radiation therapy requires prior authorization only when billed with diagnosis codes in specified ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Procedure examplesStandard radiation therapy codes listed include 77401, 77402, 77407, 77412 and related G-codes as shown in the section.

SubmissionRequests should be submitted using the UnitedHealthcare Provider Portal or by calling 866-889-8054 for radiation therapy items.

inv-44: Speech therapy age threshold

Age thresholdSpeech therapy prior authorization applies only to members 3 years of age and older.

TimingPrior authorization required after the initial evaluation and before the initial therapy visit, and for ongoing therapy visits.

Codes referencedSpeech therapy CPT codes cited include 92507, 92508, 92526 in the standard radiation therapy / speech therapy section.

Definitions and Scope Notes

inv-76: Prior authorization

DefinitionPrior authorization: A process requiring providers to obtain approval before performing certain procedures, services or supplying specified drugs or equipment.

Submission methodsRequests can be submitted online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID or by phone at 844-284-0146.

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services.

inv-77: Inpatient video electroencephalogram

RequirementPrior authorization required for inpatient video electroencephalogram monitoring (CPT 95700, 95711-95718).

ContextListed under cerebral seizure monitoring with Additional Information indicating prior authorization required for inpatient services.

CodesExamples include 95700, 95711, 95712, 95713, 95715, 95716, 95718.

inv-78: Chemotherapy injectable drugs

ScopeInjectable chemotherapy drugs (J9000-J9999) and listed J-codes require prior authorization unless administered in outpatient hospital or ambulatory surgical center per the site-based exception.

ExamplesListed chemotherapy-related J-codes include J0640, J0641, J0642, J1950, J1954, J1932.

Submission notePlease submit injectable medication prior authorization requests online using the UnitedHealthcare Provider Portal.

inv-79: DME

DefinitionDurable medical equipment (DME) entries list specific HCPCS codes that require prior authorization and include Additional Information on cost thresholds.

ThresholdCumulative rental cost or retail purchase over $500 triggers prior authorization for certain DME/prosthetics.

ExamplesDME codes cited include A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471.

inv-80: Enteral services

DefinitionEnteral services include in-home nutritional therapy and specified enteral supply codes that require prior authorization.

CodesExamples of enteral HCPCS codes listed: B9002, B9998 and E2298 with Additional Information indicating prior authorization required.

ScopeApplies to enteral services and in-home nutritional therapy delivered via gastrostomy tube as listed in the document.

inv-81: Genetic/molecular testing

DefinitionGenetic and molecular testing codes require prior authorization as listed (examples: 81162, 81403, 81407, 81412).

Additional examplesMolecular U‑codes such as 0244U, 0289U, 0293U and others are included in the genetic/molecular testing lists.

SubmissionRequests for genetic/molecular testing should follow the general submission instructions (Provider Portal recommended).

inv-82: Home health care prior authorization

ScopeHome health care prior authorization is required only in outpatient settings, including services provided in the member's home.

CodesApplicable HCPCS codes listed include G0299, G0495, G0300, G0496, G0493, S9474, G0494.

ContextListed under genetic/molecular testing and home health care sections with Additional Information indicating outpatient-only requirement.

inv-83: Unclassified/temporary code prior auth scope

ScopeUnclassified and temporary codes (e.g., C9399, J3490, J3590) require prior authorization only for specific products identified in the document (examples: Casgevy, Lantidra, Ocrevus Zunovo, Pavblu, Lupaneta Pack, Revcovi, Rivfloza).

NoteCheck the document's list for specific product-level requirements under unclassified/temporary code entries.

SubmissionSubmit requests via the UnitedHealthcare Provider Portal as indicated for non-oncology/other situations.

inv-84: Occupational/physical therapy prior auth timing

TimingOccupational and physical therapy require prior authorization after the initial evaluation and before the initial therapy visit; ongoing visits also require prior authorization as listed.

CodesTherapy CPT codes cited include 97022-97039 series and 97110-97140, 97530-97535 among others.

ActionObtain prior authorization prior to scheduling the initial therapy visit beyond the evaluation.

inv-85: Orthotics/prosthetics prior auth threshold

ThresholdOrthotics/prosthetics prior authorization required only for items with retail purchase or cumulative rental cost exceeding $500.

CodesExtensive L‑code series and related CPT codes are subject to prior authorization as listed (see orthotics/prosthetics sections).

How to obtainMany L‑codes include 'How to obtain prior authorization' references pointing to the Provider Portal or specific instructions.

inv-86: Age threshold for orthognathic surgery prior auth

Age thresholdMembers age 3 years and older require prior authorization for orthognathic surgery procedures.

Procedure typesOrthognathic surgery codes listed include 97750, 97799, 21121, 21141, 21123, 21142 and related CPT codes.

ContextNote attached under orthognathic surgery: 'Only members 3 years of age and older require a prior auth.'

inv-87: Antiemetic supply HCPCS/CPT codes

HCPCS/CPT codesAntiemetic supply HCPCS L‑codes cited include L0810, L0820, L0830, L0859 and related L‑series entries.

Price noteMultiple antiemetic entries include 'Additional Information = $500.' alongside the code listings.

RequirementThese antiemetic HCPCS/CPT supply codes require prior authorization as listed in the document.

inv-88: Antiemetic codes that require prior authorization

Codes requiring PAAntiemetic HCPCS codes and ranges listed (examples: L0810, L0820, L0830, L0859, L0710, L0700, L0640) require prior authorization.

Repeated note'Additional Information' dollar value ($500) appears in multiple antiemetic code entries.

GuidanceRefer to the antiemetic code lists in the document for the full set of L‑codes requiring prior authorization.

inv-89: How to obtain prior authorization

Primary channelSubmit prior authorization requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID.

Phone optionProviders may also submit by phone; general contact number: 844-284-0146 (radiation-specific line: 866-889-8054 as noted).

Special instructionsSome drugs (e.g., Cimzia, Synagis) require prior notification through Optum Rx prior notifications at 800-310-6826; transplant/VAD processes have separate contact instructions.

inv-90: Proton beam

DefinitionProton beam: Focused radiation therapy that uses beams of protons (tiny particles with a positive charge).

Related CPT codesExamples in the proton beam section include 77520, 77522, 77523.

ClassificationListed under special radiation modalities requiring prior authorization processes as applicable.

inv-91: SRS/SBRT

DefinitionSRS/SBRT: Stereotactic radiosurgery/stereotactic body radiation therapy listed as special/associated services requiring prior authorization for the cited codes.

CodesExamples include 77371 and G0340 listed under SRS/SBRT in the special/associated services section.

ContextIncluded in the radiation therapy grouping alongside IGRT/IMRT and other advanced modalities requiring authorization.

inv-92: VAD

ProcessFor ventricular assist devices (VAD) prior authorization: call the notification number on the member's health plan ID card, then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

DefinitionVAD: A mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow.

RequirementPrior authorization is required for VAD services and associated codes as listed in the transplants/VAD section.

inv-93: Vein procedures (saphenous vein removal/ablation)

RequirementPrior authorization required for vein procedures that remove or ablate main trunks and named branches of the saphenous veins (treating venous disease/varicose veins).

Example codesSample CPT codes listed include 36473, 37718, 36475, 37722, 36478, 37780, 37700.

ScopeApplies to procedures treating venous disease of the extremities as detailed in the transplants/vein procedures section.

OpenPayer

Prior authorization requirements for Virginia Cardinal Care

Coverage Criteria and Prior Authorization Requirements

Codes and Code Groups Requiring Prior Authorization

How to Obtain Prior Authorization — Submission & Operational Steps

Operational Coding Notes and Thresholds

Definitions and Scope Notes