Colorado Rocky Mountain Health Plans Prior Auth LTSS | OpenPayer
CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior authorization requirements for Virginia Cardinal Care LTSS
Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Virginia Long-Term Support Services (LTSS) providers for inpatient and outpatient services; includes specific service categories and codes requiring prior authorization.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeMinor / no material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by calling 844-284-0146.
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Services Requiring Prior Authorization and Coverage Notes
Prior authorization coverage stance
The policy lists services that require prior authorization and provides specific codes and notes where applicable.
Prior authorization is required for the services and service categories enumerated in this document when billed to the plan; see specific sections for code-level requirements and submission instructions.
Authorization and coverage criteria (section-level)
Prior authorization requirements and examples present in this section
ALL of the following
INPATIENT SERVICES: Prior authorization required for inpatient services (examples include inpatient video EEG and inpatient chemotherapy).
INJECTABLE CHEMOTHERAPY (OUTPATIENT): Prior authorization required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis (includes J9000-J9999 range, leucovorin J0640, levoleucovorin J0641/J0642, Lupron Depot J1950 and other listed agents).
AUDITORY IMPLANTS: Prior authorization required for cochlear implants and other auditory implants (examples: 69710, 69714, 69930, L8614); submit via UnitedHealthcare Provider Portal (UHCprovider.com).
CONTINUOUS GLUCOSE MONITORS: Prior authorization required for continuous glucose monitors for members with type 2 diabetes (examples: A4226, A9278, A4239, E0787, L8614); submit via UnitedHealthcare Provider Portal.
RECONSTRUCTIVE / COSMETIC PROCEDURES: Prior authorization required for cosmetic procedures that change appearance without restoring physiological function; reconstructive procedures treating medical conditions are listed with CPT codes and require submission via UHCprovider.com.
Follow section-specific instructions for how to obtain prior authorization (e.g., oncology vs non-oncology submission pathways).
Authorization and code guidance — cancer supportive care
Prior authorization is required for listed durable medical equipment and for in-home enteral nutritional therapy.
ALL of the following
DME: Durable medical equipment (DME) listed in this section requires prior authorization (examples include A9279, A9280, A9900, E0194, E0265, etc.).
ENTERAL NUTRITION: In-home enteral nutritional therapy, either enteral or via gastrostomy tube, requires prior authorization (codes include B9002, B9004, B9006, B9998).
COST / RENTAL THRESHOLD NOTE: Certain DME/orthotics/prosthetics items have additional prior authorization notes tied to retail purchase or cumulative rental cost thresholds (see related thresholds).
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Prior authorization and experimental flags for listed services
Lists services and medications that require prior authorization or are flagged as experimental/investigational.
SELECT SURGICAL/PROCEDURAL SERVICES: Select procedures (examples include femoroacetabular impingement repair, FESS, hysterectomy codes) require prior authorization as noted.
EXPERIMENTAL / INVESTIGATIONAL: Specific procedure and device codes are flagged as experimental/investigational and require prior authorization or additional review (examples: 33477, 36514, A4638, A6000).
INJECTABLE MEDICATIONS:
Prior authorization requirements (summary)
Prior authorization is required for many listed injectable medications and selected procedures; submission instructions differ for oncology vs non-oncology.
ALL of the following
ONCOLOGY INJECTABLES: For oncology diagnoses, follow the Cancer supportive care submission pathway for colony-stimulating factors and other oncology injectable drugs (see Cancer supportive care section).
NON-ONCOLOGY INJECTABLES: For non-oncology diagnoses, submit injectable medication prior authorization requests online at UHCProvider.com using the Prior Authorization and Notification tool or via the provider contact resources described.
PROCEDURES REQUIRING PRIOR AUTH: Selected procedures such as joint replacement (total hip/knee) and other listed surgeries require prior authorization; codes are listed in the document.
Prior authorization criteria (excerpt)
Listed services require prior authorization under the conditions noted next to codes or in 'Additional Information'.
ALL of the following
OCCUPATIONAL/PHYSICAL THERAPY: Prior authorization required after the initial evaluation and before subsequent visits for the specified CPT codes (examples include 97012, 97016, 97110, 97530, 97750, etc.).
ORTHOGNATHIC / MAXILLOFACIAL SURGERY: Prior authorization required for orthognathic and maxillofacial surgery CPT codes listed for treatment of jaw functional impairment (examples: 21121, 21127, 21143, etc.).
ORTHOTICS / PROSTHETICS: Prior authorization required only in specified situations (e.g., retail purchase, cumulative rental cost > $500) for extensive list of L-codes; see section for code-level details.
Prior authorization and investigational status (excerpt)
Selected services require prior authorization; some services are labeled 'Potentially unproven'.
ALL of the following
POTENTIALLY UNPROVEN SERVICES: Certain services are identified as 'Potentially unproven' and require prior authorization (examples: 33289, C2624).
RADIATION THERAPY: Radiation therapy services require prior authorization (see radiation therapy section for modalities and codes).
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Prior authorization criteria (excerpt)
Prior authorization or notification required for specified services and codes as listed below.
ALL of the following
ADVANCED OUTPATIENT IMAGING: Certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) require notification prior to scheduling and may require prior authorization; submit via UHCprovider.com or call 866-889-8054.
RHINOPLASTY / SEPTOPLASTY: Prior authorization required for rhinoplasty and septoplasty when performed for nasal functional impairment (examples: 30400, 30435, 30465).
SINUPLASTY / SHOULDER SURGERY / SLEEP APNEA PROCEDURES:
Prior authorization criteria (partial)
Prior authorization is required for the following service types and codes as listed below; contact instructions provided where applicable.
ALL of the following
SPEECH THERAPY: Prior authorization required after initial evaluation and before the initial therapy visit and for ongoing therapy visits (92507, 92508, 92526).
SPINAL SURGERY: Prior authorization required for spinal surgery CPT codes listed in the section (examples: 22100, 22101, 22102, 22110, 22112, etc.).
Listed under potentially unproven services (HCPCS)
Private duty nursing HCPCS/T codesHCPCSCovered
T1000
Private duty nursing
T1002
Private duty nursing
T1003
Private duty nursing
T1030
Private duty nursing
Selected CPT/HCPCS/L-codes in this sectionmixed
77331
Radiation therapy special/associated services
77370
Radiation therapy special/associated services
77399
Radiation therapy, unlisted
77470
Radiation therapy
30400
Rhinoplasty
31295
Balloon sinuplasty (example CPT)
29823
Shoulder arthroscopy
21685
Sleep apnea procedure (example)
92507
Speech-language pathology evaluation
Speech therapy codesCPTCovered
92507
Speech evaluation/therapy CPT (listed)
92508
Speech therapy CPT
92526
Speech therapy CPT
Stimulator/implantable device codesmixedCovered
63306
Bone-growth stimulator / implantable device
63307
Bone-growth stimulator / implantable device
63308
Bone-growth stimulator / implantable device
E0747
HCPCS for bone growth stimulator
L8680
Implantable neurostimulator supply (example)
Unclassified drug codesHCPCS
J3490
Unclassified drug code (requires prior authorization through Optum Transplant for specified products)
J3590
Unclassified drug code (see note)
C9399
Unclassified drug/procedure code (see note)
DME cost threshold — > $500 triggers note/PA
DME cost thresholdCost of more than $500 (home health/retail purchase/cumulative rental cost references) triggers additional prior authorization/threshold review
Threshold contextApplies to durable medical equipment (DME) entries noted under cancer supportive care; referenced in DME/orthotics sections
Related codes example
How Providers Must Submit Requests and Operational Rules
Prior Authorization
How to submit prior authorization requests
Submit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by calling 844-284-0146. 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.
Online: UHCprovider.com -> Sign In with One Healthcare ID -> Prior Authorization and Notification tool
Certain surgical procedures require prior authorization. This includes but is not limited to femoroacetabular impingement (FAI), functional endoscopic sinus surgery (FESS), spinal surgery, shoulder surgery, orthognathic surgery, rhinoplasty/septoplasty, sinuplasty, and other major operative categories. Please submit requests online using the UnitedHealthcare Provider Portal.
FAI: CPT 29914, 29915, 29916
FESS: CPT 31240, 31253-31267, 31276, 31287-31288
Terms and Operational Definitions
Prior authorization rules
Emergency/urgent carePrior authorization is not required for emergency or urgent care
Out‑of‑network providersOut‑of‑network physicians, facilities and other health care professionals must request prior authorization for all procedures and services
Submission methods summaryRequests may be submitted online via the Provider Portal or by phone (see submission portal block for details)
Prior authorization — Inpatient services
Inpatient services PA requirementPrior authorization required for inpatient services (example: inpatient video EEG and inpatient chemotherapy services)
Outpatient noteChemotherapy outpatient hospital context noted separately (prior authorization not required in some outpatient cases as indicated)
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization requirements for Virginia Cardinal Care LTSS
Policy CodePolicy N/A
Change TypeMinor / no material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by calling 844-284-0146.
title': 'Authorization and code guidance — cancer supportive care
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Numerous injectable medications (J- and Q-codes listed in the document) require prior authorization; submit via UnitedHealthcare Provider Portal or call the number provided.
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Sinuplasty, shoulder surgery (site-of-service applies), and certain sleep apnea procedures require prior authorization as listed in the document (examples: 31295–31298, 29823, 21685).
SPEECH THERAPY: Speech therapy requires prior authorization after the initial evaluation and before the initial therapy visit and for ongoing therapy visits (codes include 92507, 92508, 92526).
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Transplants and CAR T-cell therapies require prior authorization; for listed transplant/CAR T agents follow Optum/Transplant routing instructions and call the Transplant Case Management team as directed (contact numbers provided). Unclassified drug codes (J3490, J3590, C9399) for specific products require Optum Transplant review.
VAD / WOUND VAC: Ventricular assist devices (VAD) require prior authorization; contact notification number on member ID card and fax required forms to Optum VAD Case Management. Wound vac (E2402) requires prior authorization.
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Examples of HCPCS codes listed near threshold: E0471, E0620, E0652 (see DME code lists)
Rental cumulative cost threshold
Rental cumulative cost thresholdPrior authorization required when cumulative rental cost is more than $500
Applies toOrthotics and prosthetics L‑codes with cumulative rental language (see L0638, L0640, L0700, L0710 examples)
Location in docReferenced in Orthotics and Prosthetics / Cancer supportive care section under 'cumulative rental cost'
Oncology‑specific prior authorization — 38232
Oncology-specific prior authorization (code 38232)Code 38232 will only require prior authorization for an oncology diagnosis
ContextListed within CAR T-cell / Transplants section describing transplant/CAR T code requirements
Related codesOther transplant/CAR T and unclassified drug codes nearby: 32852, 32853, J3490, J3590, C9399
Spinal surgery: CPT series beginning 22100, 222xx, 225xx, 228xx, 63001, 63003, 63005, 63011, 63012 etc.
Hysterectomy procedures require prior authorization. Include relevant clinical documentation to support medical necessity when you submit the request via the Provider Portal.
Non-emergent air ambulance transport — Prior authorization required
Non-emergent air ambulance transport requires prior authorization. Confirm coverage and obtain authorization before arranging transport.
Codes requiring authorization: air ambulance HCPCS/Air ambulance CPT group (see payer-specific code list)
Contact: use Provider Portal or call the number on the member's ID card to obtain prior authorization
Prior Authorization
Joint replacement — Prior authorization required
Joint replacement procedures (total hip, total knee and related joint arthroplasties) require prior authorization. Submit the request with supporting documentation (imaging, conservative therapy history) before scheduling.
Examples of codes: 24360–24363, 24370–24371, 27120, 27125, 27130, 27132–27138, 27412, 27446–27447, 27486–27487, 29866–29868 and related joint replacement codes
Prior Authorization
Orthotics and prosthetics — Prior authorization required
Orthotics and prosthetics items require prior authorization when rental or purchase costs exceed plan thresholds or when specific L-codes are designated. Review cost thresholds and submit clinical justification and itemized cost details via the Provider Portal.
Prior authorization required for many L-codes including L0112, L0170, L0456, L0462, L0464, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L5964–L5973 mapping to L7xxx series
Certain L-codes used for prosthetics, orthotics and other specialized devices are subject to prior authorization or are flagged as potentially unproven. Submit requests with device details, clinical rationale and cost information via the Provider Portal.
Examples: L7009 (requires prior authorization), L7045, L7170, L7191, L8043, L8047, L7185, L8631 and other L5/L7/L8/L86xx series codes referenced by the plan
Potentially unproven / experimental flags associated with some L-codes (refer to payer code list)
Section locationCancer supportive care — Inpatient prior authorization notes
How to obtain prior authorization / submission portal
Submission portal (primary)Submit prior authorization requests online using the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool at UHCprovider.com)
Phone optionPhone submission available: call 844-284-0146 (general submissions) or other numbers noted for specific services
Portal access stepsSign in at UHCprovider.com using One Healthcare ID and select Prior Authorization and Notification on your dashboard
DME — Durable medical equipment (definition/reference)
DME definitionDurable medical equipment (DME) — items listed under DME/HCPCS codes within the Cancer supportive care section (examples include A9279, A9280, E0194, E0265)
PA requirementPrior authorization required for many DME items as noted in the DME section
Related HCPCS examplesSee HCPCS examples such as A9279, A9280, A9900, E0471, E0652 in the DME lists
Enteral services — in‑home nutritional therapy
Enteral services definitionIn‑home nutritional therapy delivered enterally or through a gastrostomy tube (enteral services) — codes include B9002, B9004, B9006, B9998
Prior authorizationEnteral services require prior authorization as noted in the Cancer supportive care section
Code examplesB9002, B9004, B9006, B9998 listed for enteral therapy
Prior authorization — definition/usage
Definition of 'Prior authorization' in documentDesignates services that must be reviewed and approved before provision; many entries in the Cancer supportive care section are marked 'Prior authorization required'
Usage noteUsed throughout to indicate services, procedures, devices and drugs that require pre‑service approval (e.g., DME, enteral services, injectables)
Action for providersSubmit requests via UHCprovider.com Prior Authorization and Notification tool or by phone where specified
Experimental / investigational — designation
Experimental/investigational designationCertain procedure and device codes are flagged as 'Experimental and investigational' and list 'Prior authorization' or additional review required (examples include codes 33477, 36514, 64722)
ImplicationThese services may require additional review or be considered potentially unproven; treat as requiring prior authorization per listing
ExamplesCodes called out as experimental/investigational include 33477, 36514, 64722, 65765, A4638
UHCProvider.com Prior Authorization and Notification tool
UHCProvider.com Prior Authorization and Notification toolPrimary portal for submitting prior authorization requests — access via UHCprovider.com and the Prior Authorization and Notification tab on the dashboard
Alternate contactProvider resources and contact pages for assistance are referenced; certain services list specific phone numbers (see section entries)
Portal instructionPortal sign‑in requires One Healthcare ID; instructions provided in General information section
Occupational/Physical therapy — timing rule
Therapy timing ruleOccupational and physical therapy require prior authorization after the initial evaluation and before the initial series of treatment visits
Applies to listed CPTsApplies to multiple CPT codes listed for OT/PT (e.g., 97012, 97110, 97140, 97530, 97760) in the Cancer supportive care section
Action for providersObtain prior authorization before initiating the initial series of therapy visits following the evaluation
Prior authorization notes (therapy timing and usage)
Prior authorization notes for therapy servicesPrior authorization is required after the initial evaluation and before the initial treatment/session for specified occupational, physical and speech therapy services; ongoing speech therapy visits also require prior authorization
Speech therapy specificsSpeech therapy codes 92507, 92508, 92526 require prior authorization after evaluation and for ongoing visits
Document locationTherapy prior authorization notes appear in Cancer supportive care (Occupational/physical therapy and Speech therapy sections)
Proton beam — definition
Proton beam definitionProton beam: focused radiation therapy that uses beams of protons (particles with a positive charge)
ContextListed with radiation therapy modalities and L‑codes in the Cancer supportive care section
Associated codesReferenced with L5964, L5966, L5968, L5973 entries
IGRT — image‑guided radiation therapy
IGRT definitionImage‑guided radiation therapy (IGRT) — listed as a radiation therapy modality in the document
Associated codesIGRT referenced alongside HCPCS/L‑codes such as L5964, L5966, L5968
RequirementIGRT entries are included in radiation therapy prior authorization listings
Advanced outpatient imaging — notification / PA requirement
Advanced outpatient imaging requirementAdvanced outpatient imaging (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures) requires prior authorization/notification; providers must notify prior to scheduling
How to notify/requestSubmit requests via UHCprovider.com or call 866‑889‑8054; providers ordering the procedure are responsible for notification prior to scheduling
ScopeApplies to the listed advanced outpatient imaging CPT codes and related radiology entries in the document
Speech therapy — ongoing visits
Speech therapy ongoing visitsSpeech therapy requires prior authorization after the initial evaluation and before the initial therapy visit and is required for all ongoing therapy visits
Codes citedSpeech therapy CPTs listed include 92507, 92508, 92526
Member age noteSection notes pertain to members aged 3 and older for some speech therapy entries (see source where noted)
Ventricular assist device (VAD)VAD: a mechanical pump that takes over the function of the damaged ventricle and restores normal blood flow; prior authorization required
Provider instructionsCall the notification number on the member's health plan ID card and fax the form to the Optum VAD Case Management team as directed in the document
Section locationListed under CAR T‑cell therapy / Transplants section with PA instructions