CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Surest health plans

Governs notification and prior authorization requirements for participating UnitedHealthcare providers delivering inpatient and outpatient services to members enrolled in Surest plans (including Surest Flex). Affects providers submitting authorization requests and members with Surest or Surest Flex plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Surest health plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization or notification online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-03-01policy effective date noted

UHCProvider.comportal for submissions

3 business daysSurest Flex activation lead time

Surest & Surest Flexplans affected

100+codes listed

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Prior Authorization and Coverage Criteria

General prior authorization and Surest Flex activation requirements

Services listed require either prior authorization (Surest plan) or flexible coverage activation (Surest Flex plan). Flexible coverage activation must be completed at least 3 business days before the service; services that require activation do not require prior authorization.

Applies to services listed in this document for Surest and Surest Flex plan members.

Surest plan members: prior authorization required as indicated for listed services and codes.

Surest Flex plan members: flexible coverage activation required for services marked as requiring flexible coverage activation; activation must occur at least 3 business days before the service.

Behavioral health authorization criteria

Behavioral health services that require notification or prior authorization:

ALL of the following

Acute inpatient
Residential treatment center
Partial hospitalization

Behavioral health prior authorization

Certain outpatient behavioral health–related procedures and stimulator-related CPT codes require prior authorization for both Surest and Surest Flex members.

Electronic stimulation / ultrasound to heal fractures (CPT 20974, 20975, 20979): prior authorization required for both Surest and Surest Flex members.

Breast reconstruction (non-mastectomy) and associated CPTs listed: prior authorization required for both Surest and Surest Flex members.

Where diagnosis codes (various C50.*, D05.*, Z85.*, Z90.* etc.) are listed with these CPTs, the prior authorization requirement applies as noted in the behavioral health section.

Oncology outpatient supportive care prior authorization

Cancer supportive care drugs and antiemetics require prior authorization when administered outpatient for a cancer diagnosis; oncology requests must be submitted via the Oncology prior authorization path.

Prior authorization required for cancer supportive care and antiemetic HCPCS/J‑codes listed (examples include J1442, J1447, J1449, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, J2820, J0885) when administered outpatient for a cancer diagnosis.

Some codes (listed) also require prior authorization for non‑oncology diagnoses as noted in the injectable medications section.

How to submit: log into UHCProvider.com/Prior Authorization and Notification and select 'Oncology', or call 888-397-8129 for oncology submissions.

Cardiovascular and neurological monitoring prior authorization

Cardiovascular procedures and cerebral seizure monitoring/EEG: prior authorization or flexible coverage activation applies depending on service and setting.

Selected cardiovascular procedure codes (e.g., 33285, 37224, 37228, 93580, 33289, 37225, 37229, C2624, 37220, 37226, 37230, E0616): prior authorization required for both Surest and Surest Flex members unless a Dx exception or age exception applies (see notes).

Some listed cardiovascular codes are not subject to prior authorization when billed with specific diagnosis codes (Dx exceptions referenced in document).

For certain cardiac diagnostic codes (e.g., 93653, 93656): prior authorization is required for Surest plan members and flexible coverage activation is required for Surest Flex plan members; age-based prior authorization applies for patients 18 and older as noted.

Cerebral seizure monitoring/EEG: prior authorization not required for outpatient monitoring; prior authorization required for inpatient services for Surest members and flexible coverage activation required for Surest Flex members (inpatient CPTs and inpatient video/EEG CPTs listed).

EEG / Inpatient video / cerebral seizure monitoring

Neurophysiology services (EEG, inpatient video, cerebral seizure monitoring) follow the outpatient/inpatient distinction for authorization.

Outpatient cerebral seizure monitoring: prior authorization is not required.

Inpatient cerebral seizure monitoring and inpatient video/EEG services (CPTs including 95700–95726 and related CPTs): prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex plan members.

Chemotherapy services and Continuous Glucose Monitors

Chemotherapy injectable drugs, clinical trials items, and continuous glucose monitor (CGM) devices require prior authorization for both plans as specified.

Chemotherapy injectable drugs (J9000–J9999 and other listed J/Q codes, leucovorin J0640/J0641/J0642, leuprolide J1950/J1954/J1952, and miscellaneous HCPCS-described chemotherapy injectables): prior authorization required for both Surest and Surest Flex members when administered outpatient for a cancer diagnosis.

Continuous glucose monitor (CGM) HCPCS codes (examples A4226, A4238, A4239, A9276–A9278, E0787, E2102, E2103): prior authorization required for both Surest and Surest Flex members.

How to submit oncology/chemotherapy prior authorization: use UHCProvider.com/Prior Authorization and Notification and select 'Oncology' or call 888-397-8129.

Congenital heart disease-related services

Congenital heart disease–related services and many cardiovascular procedures require prior authorization for both plans; some items include exceptions and extensive code lists.

Congenital heart disease–related services (including pre‑treatment evaluation and numerous CPTs such as 33250, 33251, 33254–33261, 33390–33391, 33404, 33414–33417, 33468, 33476, 33478, etc.): prior authorization required for both Surest and Surest Flex members.

Exceptions

Some cardiovascular codes are not subject to prior authorization when billed with specified diagnosis codes (Dx exceptions listed in the document).
Age-based exception: certain codes require prior authorization only for patients age 18 and older; see congenital heart disease section for patients under 18.

DME prior authorization

Durable medical equipment (DME) with higher retail purchase or cumulative rental cost requires prior authorization.

DME items listed with a retail purchase or cumulative rental cost greater than $1,000 require prior authorization for both Surest and Surest Flex members (examples: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297).

Retail purchase or cumulative rental cost threshold = $1,000.

ESRD dialysis notification

ESRD outpatient dialysis requires notification (or prior authorization where indicated); providers should submit via the provider portal or call the listed phone number.

To provide notification for dialysis (S1040), submit the request using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCProvider.com) or call 877-842-3210.

To enroll or refer a member to the UnitedHealthcare ESRD Disease Management program, contact Kidney Resource Service at 866-561-7518.

Procedural prior authorization

Examples of procedures that require prior authorization for Surest members and flexible coverage activation for Surest Flex members.

Procedures requiring authorization/activation

Foot surgery and FESS codes (e.g., 28292, 28296–28299, 31240, 31253–31259, 31267, 31276, 31287, 31288): prior authorization required for Surest members; flexible coverage activation required for Surest Flex members.
Gender dysphoria surgical procedures (various CPTs listed, e.g., 55970, 55980, 14000, 15734, 15738, 15750, 15757–15758, 19303, 57110, 57335, 58260, 58262, 58290–58291, 58661, 58720, 58940, etc.): prior authorization required for both Surest and Surest Flex members; some items require notification regardless of Dx.
Genetic and molecular testing performed in an outpatient setting: prior authorization required for both Surest and Surest Flex members.

Prior authorization criteria (section excerpt)

Prior authorization requirements summarized for several service categories and codes; some procedure codes require Dx‑linked prior authorization.

Genetic/molecular testing (outpatient): prior authorization required for Surest and Surest Flex members.

Home health care (T1000, T1002, T1003): prior authorization required for Surest and Surest Flex members.

Infertility services (multiple CPTs listed, e.g., 55870, 58321–58323, 58345, 58752, 58760, 58970, 58974, 58976, 76948, 89250–89253): prior authorization required for Surest and Surest Flex members.

Hysterectomy and gynecologic procedure codes: prior authorization required for Surest plan members; specified vaginal hysterectomy CPTs are listed.

Certain procedure CPTs (e.g., 52402, 54500, 54505, 55550, 58140–58146, 58545–58546, 58660–58673, 58740, 58770, 89398): these require prior authorization when submitted with the diagnosis codes listed elsewhere in the document (Dx‑linked prior authorization).

Prior authorization criteria (enumerated codes and Dx linkage)

Prior authorization is required for numerous injectable medications; submission via the provider portal and specialty pharmacy selection is described.

Prior authorization required for injectable medications listed (multiple J‑codes enumerated) for Surest and Surest Flex members; submission via UHCProvider.com/Prior Authorization and Notification and select 'Specialty' or 'Specialty Pharmacy' and the appropriate prior authorization type.

Specific injectable medication‑to‑diagnosis mappings are noted (examples: certain J‑codes linked to diagnosis codes N97.8, N97.9, N98.1, etc.)—follow the document's code‑to‑Dx guidance when submitting.

For questions about the online authorization process, providers may call Optum SGP (Specialty Guidance Program) at 1-888-397-8129.

Prior authorization criteria by service

Prior authorization and notification requirements summarized by service category; thresholds and investigational service rules are included.

Inpatient admissions (acute care hospitals, acute inpatient rehabilitation, critical access hospitals): prior authorization and notification of admission date required for both Surest and Surest Flex members.

Orthotics and prosthetics: prior authorization required when retail purchase or cumulative rental cost exceeds $1,000 for both Surest and Surest Flex members.

Pain management procedures (listed CPT/HCPCS codes such as 62320–62361, 64451, 64484, 64520, 64620, 64640, G0260, etc.): prior authorization required for both Surest and Surest Flex members.

Potentially unproven/investigational services: prior authorization required for Surest plan members; flexible coverage activation required for Surest Flex plan members.

Unclassified/temporary codes (C9399, J3490, J3590): notification/prior authorization is required only when used for specified branded drugs (examples listed); some codes (e.g., J0885) require prior authorization for oncology and non‑oncology diagnoses as noted.

Prior authorization criteria (section excerpt)

Additional prior authorization stance and conditional rules for listed services and code groups.

Prior authorization is required for numerous CPT/HCPCS codes enumerated in the document for both Surest and Surest Flex members; see specific code lists for details (spine, surgical, neurostimulator, etc.).

Conditional requirements

Radiation therapy (IMRT and related codes 77385, 77386, G6015, G6016): prior authorization required only when billed with Dx codes in specified ICD‑10 ranges (C34.00‑C34.92, C50.011‑C50.929, C61, C79.51‑C79.52, C84.7A, D05.00‑D05.92).
Stimulators/neurostimulator implantation (E0748, E0749, E0760 and related codes): prior authorization required for both plans; some stimulator entries include diagnosis‑based exceptions noted in the document.

Authorization criteria and process (partial)

Authorization process notes and exceptions for transplant, radiopharmaceuticals, stimulators, and other services.

Prior authorization required for listed CPT/HCPCS codes for both Surest and Surest Flex members; providers must follow the submission instructions shown with each service (portal selection or phone numbers as noted).

Special processes

Transplant and cellular/gene therapy services (including bone marrow harvest and cellular therapies): prior authorization required for both Surest and Surest Flex members; providers should call 888-936-7246 for transplant-related prior authorization and follow document instructions for cellular/gene therapy codes (e.g., 38240, S2150, etc.).
Therapeutic radiopharmaceuticals: submit prior authorization via UHCProvider.com/Prior Authorization and Notification homepage and select 'Oncology' (HCPCS ranges A9513–A9590, A9699 referenced).

Prior authorization criteria by service/code

Specific code groups and services listed in-line require prior authorization for both Surest and Surest Flex members, with additional process instructions where noted.

Transportation services (A0430, A0431, A0435, A0436, S9960, S9961, 0071T, 0072T): prior authorization required for both Surest and Surest Flex members.

Select vascular, infusion, and related procedures (e.g., 36470–36476 series, 36478–36479, 37243, 37700, 37718, 37722): prior authorization required for both Surest and Surest Flex members.

Ventricular assist devices (VAD) (e.g., 33927, 33928, 33975, 33976, 33982, 33983): prior authorization required for both Surest and Surest Flex members; providers should call 888-936-7246 and fax the form to the Optum VAD Case Management Team at 855-282-8929.

Codes and Code Lists Requiring Prior Authorization

Arthroscopy CPT CodesCPTCovered

29871-29916 (arthroscopy series)

Arthroscopy CPT codes listed; prior authorization required for Surest plan members; flexible coverage activation for Surest Flex members

Bariatric surgery CPT and DxmixedCovered

43644-43888 (bariatric series)	Bariatric surgery CPT codes listed; prior authorization required for Surest plan members; flexible coverage activation for Surest Flex members
E66., Z68.	ICD-10 diagnosis codes related to obesity/weight categories referenced for bariatric prior authorization

Electronic stimulation & Breast reconstructionmixedCovered

20974, 20975, 20979	Electronic stimulation/ultrasound to heal fractures; listed as requiring prior authorization for both Surest and Surest Flex members
15771, 19300-19396, L8600	Breast reconstruction (non-mastectomy) CPT/HCPCS codes referenced; prior authorization required
C50.*	ICD-10 codes for breast cancer diagnoses referenced in relation to reconstruction prior authorization

Behavioral health / Stimulator-related CPT CodesCPTCovered

20974	Listed behavioral health / stimulator-related code; prior authorization required
20975	Listed behavioral health / stimulator-related code; prior authorization required
20979	Listed behavioral health / stimulator-related code; prior authorization required

Cancer supportive care - Antiemetics & Supportive DrugsHCPCSCovered

J1454	Palonosetron/fosnetupitant (Akynzeo) - antiemetic
J0185	Aprepitant (Cinvanti) - antiemetic
J1453	Fosaprepitant (Emend) - antiemetic
J1449	Eflapegrastim-xnst (Rolvedon) - colony-stimulating factor
J2506	Pegfilgrastim (Neulasta) - colony-stimulating factor
J2820	Sargramostim (Leukine)
J0885	Epoetin alfa (Epogen)

Cartilage implants HCPCSHCPCSCovered

J7330

Cartilage implant

Cardiovascular system codesmixedCovered

33285	Cardiovascular procedure code listed; prior authorization required
37224	Cardiovascular procedure code (may have Dx exceptions); prior authorization required
93580	Cardiovascular diagnostic code with age exception (prior authorization required for patients 18 and older)

EEG / Inpatient video CPT CodesCPTCovered

95700-95726

Inpatient video/EEG and related neurophysiology CPT codes referenced; prior authorization required for inpatient services (outpatient monitoring not required)

Chemotherapy injectable HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range; prior authorization required when administered outpatient for a cancer diagnosis
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Leuprolide acetate
J1954	Leuprolide acetate (additional)
J1952	Leuprolide

Continuous glucose monitor HCPCS CodesHCPCSCovered

A4226	CGM related HCPCS
A4238	CGM related HCPCS
A4239	CGM related HCPCS
A9276	CGM related HCPCS
A9277	CGM related HCPCS
A9278	CGM related HCPCS
E0787	CGM related HCPCS
E2102	CGM related HCPCS
E2103	CGM related HCPCS

Various CPT codes requiring PACPTCovered

11960-33926, 93580-93598, 33692-33895, 33720-33894, 67900-67966, Q2026

Large series of CPT codes listed under congenital heart disease, cosmetic/reconstructive, and other services that require prior authorization

Diagnosis codes affecting PA requirementICD-10

C43.*

ICD-10 codes (melanoma) listed as exempting prior authorization when billed with certain CPTs

Diagnosis examples (C43/C44 family)ICD-10

C43.0	Malignant melanoma of skin - specific lesion site codes listed
C44.01	Malignant neoplasm of skin of lip (examples of C44 family codes listed)

DME / HCPCS examples subject to PA thresholdHCPCS

E0300	Seat lift chair (example DME HCPCS code listed)
E1016	Power mobility device components (example listed)

Selected genetic testing / molecular codesmixedCovered

81162	BRCA genetic testing code listed
81163	BRCA genetic testing code listed
81164	BRCA genetic testing code listed
81432	Genetic testing/molecular code listed
81228	Genetic testing code listed
81229	Genetic testing code listed
81349	Genetic testing code listed
81400	Genetic testing code listed

Additional molecular / other lab codesmixedCovered

81420	Molecular testing code listed
81427	Molecular testing code listed
81431	Molecular testing code listed
81507	Molecular testing code listed
87505	Lab code listed
0018U	Proprietary lab code listed
0022U	Proprietary lab code listed

Selected injectable HCPCS / J-codesHCPCS | mixed

J7170	Hemophilia-related injectable (example listed)
J7183	Hemophilia/other injectable (example listed)
90283	Immune globulin administration
90284	Immune globulin administration
J1459	Immune globulin product
J1551	Immune globulin product

Procedure CPT codes called outCPT

52402	Procedure code listed requiring prior authorization when submitted with specified Dx codes
54500	Procedure code listed
58545	Procedure code listed
89398	Specimen or lab related code listed

Orthotics and prosthetics HCPCS L-codes (partial)HCPCSCovered

L0220	Orthotics/prosthetics HCPCS code listed
L0482	Orthotics/prosthetics HCPCS code listed
L1700	Orthotics/prosthetics HCPCS code listed
L1710	Orthotics/prosthetics HCPCS code listed
L2038	Orthotics/prosthetics HCPCS code listed
L3900	Orthotics/prosthetics HCPCS code listed
L5960	Orthotics/prosthetics HCPCS code listed
L7007	Orthotics/prosthetics HCPCS code listed

Pain management CPT / HCPCS codes (partial)CPT | HCPCSCovered

62320	Epidural or spinal injection code listed under pain management
64451	Nerve block / chemodenervation procedure
G0260	Hospital outpatient clinic visit code referenced

Chemotherapy / drug J-codes (examples)HCPCSCovered

J2323	Chemotherapy/drug J-code example listed
J1442	Chemotherapy/drug J-code example listed
J2506	Pegfilgrastim (Neulasta) - colony-stimulating factor
J1305	Drug J-code referenced for rare conditions

Radiation therapy conditional Dx rangesICD-10Covered

C34.00-C34.92	Diagnosis code range that triggers radiation therapy prior authorization when billed with IMRT and related codes
C50.011-C50.929	Diagnosis code range for breast cancer that conditions radiation therapy prior authorization
C61	Diagnosis code used to determine when radiation therapy prior authorization is required
C79.51-C79.52	Diagnosis code range used for radiation therapy prior authorization
C84.7A	Diagnosis code used to determine when radiation therapy prior authorization is required
D05.00-D05.92	Diagnosis code range used to determine when radiation therapy prior authorization is required

Selected CPT codes requiring prior authorization (partial list)CPTCovered

63048	CPT code listed as requiring prior authorization
63055	CPT code listed as requiring prior authorization
63276	CPT code listed as requiring prior authorization
22100	CPT code listed as requiring prior authorization
22533	CPT code listed as requiring prior authorization
22840	CPT code listed as requiring prior authorization
63001	CPT code listed as requiring prior authorization

Selected HCPCS codes / ranges referencedHCPCSCovered

E0748	HCPCS code for neurostimulator-related device
E0749	HCPCS code for neurostimulator-related device
E0760	HCPCS code for neurostimulator-related device
A9513-A9590	Therapeutic radiopharmaceutical HCPCS range referenced
A9699	Therapeutic radiopharmaceutical HCPCS referenced

Transplant / Cellular & Gene Therapy codesmixedCovered

38240	Bone marrow harvest
S2150	Related to transplant/cellular products
C9399	Miscellaneous code used for cellular/gene therapy
J3392	Drug HCPCS/J-code referenced for cellular/gene therapy

Chemotherapy / CAR-T / Gene therapy related procedure codesmixed

S2065	Code listed in chemotherapy services section (cell/gene therapy related)
S2060	Code listed in chemotherapy services section
S2061	Code listed in chemotherapy services section
S2054	Code listed in chemotherapy services section
S2140	Code listed in chemotherapy services section
S2142	Code listed in chemotherapy services section
S2152	Code listed in chemotherapy services section
47135	Procedure code referenced under transplant/chemotherapy services
47143	Procedure code referenced
47147	Procedure code referenced

inv-44: Age-based prior authorization

RulePrior authorization required for patients age 18 and older for specified cardiovascular/congenital heart disease codes (see congenital heart disease exceptions for patients under 18).

Applies to

How to Submit and Provider Responsibilities

Prior Authorization

How to submit prior authorization/notification

Submit prior authorization/notification online via the UnitedHealthcare Provider Portal (UHCprovider.com). Sign in with One Healthcare ID, select the Prior Authorization and Notification tab, then choose the appropriate prior authorization type (for example: Oncology, Specialty Pharmacy). If you need assistance, call 877-842-3210 for general authorization questions.

Online: UHCprovider.com → Sign In → Prior Authorization and Notification tab
Oncology-specific submissions: On the Prior Authorization and Notification homepage select 'Oncology' from the dropdown
For specialty medication questions or oncology support call Optum Specialty Guidance Program: 1-888-397-8129
General authorization support: 877-842-3210

Note

Surest Flex flexible coverage activation

Surest Flex members: some services require activation of the plan’s flexible coverage feature instead of prior authorization. The member must activate flexible coverage at least 3 business days before the service. Services that require flexible coverage activation do not require separate prior authorization.

Key Terms and Definitions

inv-89: Surest Flex activation

DefinitionSurest Flex activation (Flexible coverage activation): additional activation required for Surest Flex plan members for listed services; activation must occur at least 3 business days before the service.

EffectServices that require flexible coverage activation do not require standard prior authorization when activation is completed.

Applies toSurest Flex plan members only.

inv-90: Submission methods

Online portalSubmit prior authorization or notification using the Prior Authorization and Notification tool on UHCProvider.com (One Healthcare ID).

PhoneCall 877-842-3210 for prior authorization/notification submissions when phone is used as alternative.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Surest health plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization or notification online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 877-842-3210.

SourceLink

On This Page

Surest and Surest Flex plan members (Surest Flex uses flexible coverage activation for inpatient services).

Supporting codes/examplesExample codes noted in this section: 93653, 93656 (age-based note applies).

inv-45: Oncology outpatient administration

TriggerPrior authorization required when cancer supportive care or antiemetic drugs are administered in an outpatient setting for a cancer diagnosis.

How to submit (oncology)Submit via UHCProvider.com Prior Authorization and Notification tool and select 'Oncology', or call 888-397-8129.

Examples of drugsListed J-codes include J1442, J1447, J1449, J2506 and Q-codes Q5101, Q5125 (see injectable medications section for full list).

inv-46: DME retail purchase or cumulative rental threshold

ThresholdRetail purchase or cumulative rental cost over $1,000 triggers prior authorization for DME and for orthotics/prosthetics.

Applies toBoth Surest and Surest Flex plan members.

Example HCPCS codesExamples listed where threshold applies: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297; orthotics/prosthetics L-codes referenced in orthotics section.

inv-47: Place of service restriction example

Example restrictionSome enzyme replacement therapies for enzyme deficiency (e.g., Gaucher disease) are limited to place of service (POS) 19 and 22 only.

ContextPlace-of-service limitation applies to enzyme replacement therapy billed with specific diagnosis codes (see chemotherapy services / enzyme replacement entries).

Relevant codesExamples referenced in enzyme replacement therapy section include J0567, J1203 and other enzyme therapy J-codes.

inv-48: Orthotics/prosthetics cost threshold

Cost thresholdOrthotics and prosthetics with a retail purchase or cumulative rental cost of more than $1,000 require prior authorization.

Applies toBoth Surest and Surest Flex plan members.

How notedThreshold is stated in the orthotics and prosthetics section as the trigger for prior authorization for the listed codes.

inv-49: Radiation therapy prior authorization conditionality

Conditional requirementPrior authorization for radiation therapy (IMRT and related codes) is required only when billed with diagnosis codes in the specified ICD-10 ranges (e.g., C34.00-C34.92, C50.011-C50.929, C61, C79.51-C79.52, C84.7A, D05.00-D05.92).

Relevant procedure codesExamples of radiation therapy CPT/HCPCS codes cited: 77385, 77386, G6015, G6016.

Submission notePrior authorization pathway: IMRT/therapeutic radiopharmaceuticals submitted via UHCProvider.com (Oncology selection).

Member must activate flexible coverage ≥3 business days before service
Flexible coverage activation replaces prior authorization for listed services

Prior Authorization

Cerebral seizure monitoring/EEG authorization rules

Cerebral seizure monitoring, EEG and inpatient video monitoring have specific authorization rules: outpatient EEGs generally do not require prior authorization; inpatient EEG/video monitoring and certain monitoring CPT codes do require prior authorization for Surest plan members and flexible coverage activation for Surest Flex members. Verify setting (outpatient vs inpatient) and submit authorization when the service is inpatient.

Outpatient EEG: prior authorization not required
Inpatient EEG/video monitoring: prior authorization required for Surest plan members; Surest Flex members require flexible coverage activation
Representative CPT/monitoring codes requiring inpatient authorization: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726

Prior Authorization

Oncology prior authorization submission

Oncology and chemotherapy-related prior authorizations must be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal and selecting 'Oncology' as the authorization type. Some oncology supportive care drugs and injectable chemotherapy agents require PA for non-oncology diagnoses as well.

Submit oncology prior authorization: UHCprovider.com → Prior Authorization and Notification → select 'Oncology'
For chemotherapy injectable drugs (J9000–J9999 and Q-codes) and miscellaneous HCPCS billed agents, prior authorization is required when administered outpatient for a cancer diagnosis
Cancer supportive care agents (e.g., J1442, J1447, J1449, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) may require prior authorization for non-oncology DX — check drug-specific guidance
For questions about specialty medication submission and reviews call Optum SGP: 1-888-397-8129

Prior Authorization

Cardiovascular/congenital heart disease PA

Cardiovascular and congenital heart disease procedures (including adults per document guidance) require prior authorization. For many cardiac-related procedures and devices, providers must call the designated specialty line for prior authorization and follow any fax/form instructions.

For cardiovascular prior authorization call: 888-936-7246
Ventricular assist devices (VAD) require prior authorization; after calling 888-936-7246, fax the nurse-provided form to Optum VAD Case Management Team at 855-282-8929
Prior authorization required for Surest and Surest Flex members for listed cardiac procedure codes — verify age-specific instructions (e.g., adults) in the cardiovascular section

Prior Authorization

CGM and chemotherapy injectable drugs PA

Continuous glucose monitors (CGMs) and many chemotherapy injectable drugs require prior authorization for both Surest plan and Surest Flex plan members. Submit PA requests through the Provider Portal and include required clinical documentation.

CGM HCPCS and supply codes (examples listed in source: A4226, A4238, A4239, A9276–A9278, E0787, E2102, E2103) require prior authorization
Chemotherapy injectable drugs (J-codes, Q-codes, unassigned HCPCS/miscellaneous codes) require prior authorization when administered outpatient for cancer diagnoses
Submit PA online: UHCprovider.com → Prior Authorization and Notification; choose Specialty or Oncology as appropriate

Prior Authorization

Gender dysphoria treatment prior authorization and relevant Dx codes

Gender dysphoria treatments (including listed surgical and reconstructive CPT codes) require prior authorization or notification regardless of diagnosis code in many cases. When diagnosis-driven authorization is required, use the listed gender dysphoria ICD-10 codes.

Prior authorization required for both Surest and Surest Flex members for listed gender-affirming procedures (examples from source: 14000, 14001, 14041, 15734, 15738, 15750, 15757, 15758, 19303, 53410, 53430, 55970, 55980, 57110, 57335, 58260, 58262, 58290, 58291, 58661, 58720, 58940, 64856, 64892, 64896)
When a diagnosis is required, use ICD-10 codes: F64.0, F64.1, F64.2, F64.8, F64.9 or Z87.890
Notification or prior authorization may be required regardless of DX for certain gender dysphoria services — confirm via Provider Portal submission guidance

Prior Authorization

Procedure codes requiring Dx-linked prior auth

Certain procedures require a diagnosis-linked prior authorization — the claim must include the specified ICD-10 diagnosis codes to meet PA requirements. Verify the code-to-procedure mapping before submission.

Examples of procedures requiring Dx-linked prior authorization include (not exhaustive): 52402, 54500, 54505, 55550, 58140, 58145, 58146, 58545, 58546, 58660–58672, 52402 et al. — confirm associated ICD-10 ranges on the portal
For oncology-related procedures or drugs, prior authorization may be required only when billed with cancer diagnosis codes (e.g., ranges C34.00–C34.92, C50.011–C50.929, C61, etc.)

Prior Authorization

Chemotherapy/medication prior authorization references

Chemotherapy and many injectable medications follow specialty prior authorization processes. Unclassified/temporary codes (C9399, J3490, J3590) require PA only for specific products; new-to-market medications should be checked against the Review at Launch medication list. Predetermination is recommended for newly approved drugs.

For injectable medications and chemotherapy: submit PA via UHCprovider.com → Prior Authorization and Notification; select 'Specialty' or 'Oncology' as appropriate
Unclassified/temporary HCPCS codes C9399, J3490, J3590 require PA only for certain products (examples: Nulibry®, Ocrevus Zunovo™, Revcovi®, Rivfloza™) — check current list
Check the 'Review at Launch for New to Market Medications' policy for drugs newly approved by FDA; predetermination is highly recommended

Prior Authorization

Prostate procedures prior authorization

Prostate procedures listed in the source require prior authorization. Confirm whether the member is Surest or Surest Flex and apply flexible coverage activation rules when applicable.

Prior authorization required for both Surest and Surest Flex members for codes: 52441, 55874
Prior authorization required for Surest plan members (and flexible coverage activation required for Surest Flex members) for codes: 52442, 53850

Prior Authorization

Sleep disorder and related surgical prior authorization; Surgical and spine procedure prior authorization (bulk list)

Sleep disorder diagnoses and related surgical treatments (including sleep studies, oral/pharyngeal surgeries, maxillomandibular advancement, uvulopalatoplasty, and implantable stimulators) require prior authorization for inpatient or outpatient settings as listed. Spine and many surgical procedures require prior authorization — review the bulk CPT list and submit PA prior to scheduling.

Sleep disorder services: prior authorization required for both Surest and Surest Flex members for inpatient and applicable outpatient procedures; sleep study CPTs: 95805, 95807, 95808, 95810
Maxillomandibular advancement and related oral/pharyngeal surgeries (e.g., 21685, 41599, 42145) require prior authorization
Apnea-related reconstructive surgeries including laser-assisted procedures require PA
Spinal cord stimulators and other implantable neuromodulation devices require prior authorization (examples: 63650–63664, 63685, 64553, 64570)
Large set of surgical and spine CPT codes listed in the source require prior authorization for both Surest and Surest Flex members (examples include many 2xxxx–6xxxx series codes such as 20930–20939, 22101–22614, 22800–22899, 27279–27280, 63003–63172, 63075–63103, etc.) — verify full code list on the Provider Portal before scheduling

Prior Authorization

How to obtain prior authorization / contact

How to obtain prior authorization / contact: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal for most requests. For specialty or procedure-specific lines, use the phone numbers below. Include all required documentation and diagnosis codes when submitting to avoid delays.

Primary submission: UHCprovider.com → Sign In → Prior Authorization and Notification tab
General phone support for notifications/authorization: 877-842-3210
Oncology specialty submissions/support: Optum Specialty Guidance Program 1-888-397-8129
Cardiovascular and transplant/VAD prior authorization: call 888-936-7246; VAD fax (after nurse form): 855-282-8929
Include relevant CPT/HCPCS and ICD-10 diagnosis codes and clinical documentation with all requests

Oncology & specialty medsFor oncology submissions select 'Oncology' on the portal or call 888-397-8129; injectable medications submitted via 'Specialty' or 'Specialty Pharmacy' selection as directed.

inv-91: Oncology prior authorization

RequirementOncology prior authorization required for chemotherapy/injectable cancer supportive care drugs administered outpatient for a cancer diagnosis.

How to submitSubmit via UHCProvider.com Prior Authorization and Notification tool; select 'Oncology' or call 888-397-8129.

Included drugs/codesIncludes J9000–J9999 range, leucovorin (J0640–J0642), leuprolide codes (J1950, J1952, J1954) and specified J/Q codes listed in the cancer supportive care section.

inv-92: Flexible coverage activation

DefinitionFlexible coverage activation: the Surest Flex requirement to activate coverage for certain inpatient services (must be activated at least 3 business days prior).

Contrast with prior authActivation replaces standard prior authorization for the listed services for Surest Flex members but does not apply to Surest plan members.

Example applicationUsed for inpatient cerebral seizure monitoring/inpatient video/EEG and other inpatient services where Flex activation is specified.

inv-93: Clinical trials

DefinitionClinical trials: rigorously controlled studies of new drugs, devices, or treatments on eligible human subjects under institutional review oversight; certain clinical trial codes (S9988, S9990, S9991) require prior authorization.

Applies toPrior authorization required for clinical trial codes for both Surest and Surest Flex members as noted.

SubmissionSubmit clinical trial prior authorization via UHCProvider portal per instructions in chemotherapy/services section.

inv-94: Flexible coverage activation

DefinitionFlexible coverage activation: additional activation required for Surest Flex members, especially when services are investigational or marked as requiring Flex activation.

TimingMust be activated at least 3 business days before the service.

EffectWhen activated, flexible coverage replaces prior authorization requirement for the specified services for Surest Flex members.

inv-95: DME prior authorization threshold

ThresholdPrior authorization required when retail purchase or cumulative rental cost exceeds $1,000 for listed DME and orthotics/prosthetics codes.

Applies toSurest and Surest Flex plan members.

Example codesDME examples: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297; orthotics/prosthetics L-codes referenced elsewhere (see orthotics section).

inv-96: ESRD dialysis notification

ProcessTo provide notification for ESRD dialysis, submit via the Prior Authorization and Notification tool on UHCProvider.com or call 877-842-3210.

Referral/enrollmentTo enroll or refer a member to UnitedHealthcare ESRD Disease Management, contact Kidney Resource Service at 866-561-7518.

Relevant codeS1040 is the HCPCS code referenced for ESRD dialysis notification/process.

inv-97: Prior authorization (for Surest/Surest Flex)

DefinitionPrior authorization: formal review required for specified services for Surest plan members; for Surest Flex members some services require flexible coverage activation instead.

SubmissionSubmit prior authorization requests via UHCProvider.com Prior Authorization and Notification tool or by phone per submission guidance.

Injectable meds noteRequests for many injectable medications should select 'Specialty' or 'Specialty Pharmacy' on the portal; see injectable medications section for J-code lists.

inv-98: Dx-linked prior authorization

RequirementPrior authorization required for numerous injectable medications (J-codes listed) for both Surest and Surest Flex members.

How to submitLog into UHCProvider.com/Prior Authorization and Notification and select 'Specialty' or 'Specialty Pharmacy' as appropriate.

Unclassified codesFor unclassified/temporary codes (C9399, J3490, J3590) notification/prior authorization applies only to specified branded drugs (e.g., Nulibry, Ocrevus Zunovo, Revcovi); check Review at Launch policy for new-to-market drugs.

inv-99: Injectable medications

DefinitionInjectable medications: drugs administered IV, subcutaneously, or intramuscularly; many require prior authorization for Surest and Surest Flex members.

Submission pathwaySubmit via UHCProvider.com/Prior Authorization and Notification and select 'Specialty' for specialty injectables.

ExamplesIncluded J-code ranges and examples: J9000–J9999, J0640–J0642, various J- and Q-codes listed in chemotherapy/supportive care sections.

inv-100: Unclassified/temporary codes (C9399, J3490, J3590)

RuleNotification/prior authorization for unclassified/temporary codes C9399, J3490, J3590 is required only when used for specified branded drugs (examples include Nulibry, Ocrevus Zunovo, Revcovi).

ActionCheck the Review at Launch for New to Market Medications policy and consider predetermination for newly approved drugs on the Review at Launch list.

Related noteSome temporary/unclassified codes may still require prior authorization for oncology and non-oncology diagnoses as specified elsewhere.

inv-101: Flexible coverage activation

DefinitionFlexible coverage activation: Surest Flex plan requirement to activate coverage for certain services, particularly investigational services; activation replaces prior authorization when completed.

TimingMust be activated at least 3 business days before the service.

Applies toSurest Flex plan members only; Surest plan members require standard prior authorization as indicated.

inv-102: Flexible coverage activation

ApplicationFlexible coverage activation is required for inpatient cerebral seizure monitoring/inpatient video/EEG services for Surest Flex members; outpatient monitoring does not require prior authorization.

ContrastSurest plan members require prior authorization for inpatient services; outpatient EEG/inpatient video monitoring may be exempt from prior authorization per section notes.

Relevant codesCodes referenced in this context include 27412, 27415, 27416, 29866–29868 and EEG/video CPT codes 95700–95726.

inv-103: Prior authorization required

RequirementPrior authorization and notification of admission date required for acute care hospitals, acute inpatient rehabilitation and critical access hospitals for both Surest and Surest Flex members.

How to submitUse the Prior Authorization and Notification tool on UHCProvider.com or call the listed phone number per submission guidance.

Applies toInpatient admissions and related post-acute services listed in the document.

inv-104: Stimulators

RequirementPrior authorization required for implantation of stimulators and related neurostimulator device codes for both Surest and Surest Flex members.

Relevant HCPCSDevice HCPCS referenced include E0748, E0749, E0760 for neurostimulator-related devices.

Flex activationSome stimulator-related services may require flexible coverage activation for Surest Flex members as noted in the stimulators section.

inv-105: Transplant / cellular and gene therapy services

RequirementPrior authorization is required for transplant and transplant-related services (including pre-treatment, evaluation and bone marrow harvest) for both Surest and Surest Flex members. Call 888-936-7246 for transplant prior authorization.

Examples/codesExamples include bone marrow harvest (38240–38242) and cellular/gene therapy-related codes such as C9399, J3392–J3394 and various Q-codes referenced.

ProcessProviders instructed to call 888-936-7246 for transplant-related prior authorization; follow portal instructions for therapeutic radiopharmaceuticals (Oncology path).

inv-106: Therapeutic Radiopharmaceuticals

SubmissionTo submit prior authorization for outpatient therapeutic radiopharmaceuticals, log into UHCProvider.com/Prior Authorization and Notification and select 'Oncology'.

HCPCS rangesTherapeutic radiopharmaceutical HCPCS examples/ranges referenced include A9513–A9590 and A9699.

Applies toPrior authorization required for therapeutic radiopharmaceuticals and related services for both Surest and Surest Flex members as indicated.

inv-107: Ventricular assist devices (VAD)

RequirementPrior authorization required for ventricular assist devices (VAD) for both Surest and Surest Flex members; providers must call 888-936-7246 and then fax the form provided by the nurse to Optum VAD Case Management Team at 855-282-8929.

Relevant CPT codesVAD CPT examples listed include 33927, 33928, 33975, 33976, 33982, 33983.

Process noteCall to obtain the required form from the nurse; fax completed form to Optum VAD Case Management Team per instructions.