Prior authorization criteria (partial list from this segment). Consolidated list of services, codes, and instructions requiring prior authorization or flexible coverage activation.
ALL of the following apply unless otherwise noted:
a. Prior authorization is required for Surest plan members unless a specific service notes otherwise.
b. Flexible coverage activation is required for Surest Flex plan members for services listed as "Flexible coverage activation required"; activation must occur at least 3 business days before service and those services do not additionally require prior authorization unless explicitly stated.
2. Behavioral health services:
a. Notification/prior authorization required for:
- Acute inpatient admission
- Residential treatment center
- Partial hospitalization
b. To submit behavioral health requests: submit notification online or call 877-237-0006. For Applied Behavior Analysis (ABA) outpatient services follow Optum Provider Express ABA submission steps and select "Care Advocate Request" when prompted for plan type.
3. Electronic bone stimulation (fracture healing):
- CPT/HCPCS: 20974, 20975, 20979
- Prior authorization required for both Surest and Surest Flex plan members.
4. Oncology / Chemotherapy / Cancer supportive care:
a. Prior authorization is required for outpatient administration of chemotherapy for a cancer diagnosis.
b. Injectable chemotherapy drugs (J9000-J9999 and related J/Q codes) require prior authorization. This includes: leucovorin (J0640), levoleucovorin (J0641, J0642), leuprolide products (J1950, J1954, J1952), and other chemotherapy J- and Q-codes listed in the cancer supportive care section.
c. Specific antiemetic and supportive drug codes requiring prior authorization include: J1454 (palonosetron/fosnetupitant – Akynzeo), J0185 (aprepitant – Cinvanti), J1453 (fosaprepitant – Emend), J1456 (granisetron extended release – Sustol), J1627 (bone-modifying agent denosumab), J1449, J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, plus pegfilgrastim and filgrastim biosimilars (Q5111, Q5108, Q5120, Q5122, Q5125, Q5110, etc.).
d. For oncology prior authorizations submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (select Oncology) or call 888-397-8129 for oncology submissions.
e. Unclassified/temporary codes (C9399, J3490, J3590, J1449, Q5110, Q5125, etc.) may require prior authorization depending on drug and indication; see the Review at Launch and cancer supportive care notes.
5. Chemotherapy services and related supplies:
- Chemotherapy services and J7330 (and other chemotherapy-related codes) require prior authorization for both Surest and Surest Flex plan members.
6. Cardiovascular / Device and procedure codes (selection):
a. Several cardiovascular procedure codes require prior authorization for Surest plan members and require flexible coverage activation for Surest Flex plan members (examples listed in the full policy): 33285, 33289, 332? series and select endovascular codes (37220, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 372?*).
b. Some electrophysiology codes (e.g., 93653, 93656) are prior authorization required for Surest plan members and require flexible coverage activation for Surest Flex plan members.
c. Certain codes have age or diagnosis exceptions noted in the source (e.g., some prior authorization requirements apply only to adults or only when not associated with specified Dx codes).
7. Injectable medications (non-oncology) and DME:
a. Many injectable drugs billed under J-codes and Q-codes require prior authorization; see unclassified/temporary codes and the injectable medication lists (e.g., J0896, J1437, J1439, Q0138, J0256, J0257, J0517, J2182, J2356, J2357, J2786).
b. DME/prosthetic items with a retail purchase or cumulative rental cost > $1,000 require prior authorization (examples: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297).
8. Genetic testing / Laboratory services:
- Genetic and molecular tests performed in an outpatient setting require prior authorization. Example CPT/PLA codes include 0417U, 0419U, 0423U, 0448U, 0425U, S3870.
9. Home health, transplant, inpatient admissions and facility notifications:
a. Home health care services require prior authorization for both Surest and Surest Flex plan members (T1000, T1002, T1003, etc.).
b. Transplant and transplant-related services (including evaluation and pre-treatment) require prior authorization for both Surest and Surest Flex plan members; contact 888-936-7246 for transplant prior authorization instructions.
c. Prior authorization and notification of admission date is required for acute and post-acute inpatient facilities (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, LTACHs, SNFs).
10. Surgical and specialty procedures (selection):
- Many elective and specialty surgeries require prior authorization for Surest plan members and flexible coverage activation for Surest Flex plan members. Examples include: arthroplasty series (e.g., 24365, 27120, 23470–23474, 24360–24363), bariatric surgery codes (43659, 43772, 43774, 43886–43888), foot surgery codes (28285, 28289, 28291–28292, 28296–28299), functional endoscopic sinus surgery (31240, 31253–31259, 31267, 31276, 31287–31288), hysterectomy family of codes (including 58267, 58270, 58292, 58294, 58150, 58152, 58180, 58541–58553), spine surgery codes (20930, 20931, 20939, 22101–22116, 22206–22226, 22510–22515, 22532, 22556, 22585, 22610, 22614, 22800–22808, etc.), and others (rhinoplasty 30400–30460 family, sinuplasty 31295–31299).
11. Radiation therapy / Radiopharmaceuticals:
- Radiation therapy services and special radiation procedures (IGRT, SRS/SBRT, associated planning and image guidance codes such as 77014, 77331, 77370, 77387, 77399, 77470, 77385–77386, G6015–G6017, G6001–G6009, G6010–G6014) require prior authorization; radiopharmaceutical outpatient therapeutics require oncology prior authorization via the Provider Portal (Oncology selection). Some radiation therapy codes require prior authorization only when billed with oncology Dx codes in specified ranges (C34.xx, C50.xx, C61, C79.51–C79.52, etc.).
12. Neuromodulation and implantable devices:
- Spinal cord stimulators (L8682–L8688 series) require prior authorization for implantation. SCS and spinal neuromodulation procedure/CPT codes (63650, 63655, 63661, 63663, 63664, 63685, 63688, 64553) require prior authorization.
13. Ventricular assist devices (VAD) and other high-acuity devices:
- VADs require prior authorization for both Surest and Surest Flex plan members; contact 888-936-7246 and follow Optum VAD Case Management fax instructions.
14. Transportation and certain ancillary services:
- Nonemergency transportation (A0430, A0431, A0435, A0436, S9960, S9961) requires prior authorization for both Surest and Surest Flex plan members.
- Always verify whether a given service requires prior authorization or only flexible coverage activation by checking the member's specific plan (Surest vs Surest Flex) and the policy code-level details.
- For oncology and radiation oncology prior authorizations, prefer the UnitedHealthcare Provider Portal Prior Authorization and Notification tool and select the appropriate specialty (Oncology or Radiation Oncology).
- Unlisted/temporary codes and new-to-market medications may have special Review at Launch requirements; predetermination is recommended for such drugs.