CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Maryland

Lists services, codes, and instructions for submitting prior authorization requests for participating UnitedHealthcare Community Plan of Maryland providers; governs inpatient and outpatient services and affects network and out-of-network providers (except emergency/urgent care).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Maryland

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number on the member's ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dozensCPT/HCPCS/ICD-10 codes listed for prior authorization

online & phonesubmission methods for prior authorization

exemptemergency/urgent care exemption

abortionstate carve-out noted

manydistinct procedure/device codes listed

Services and Conditions Requiring Prior Authorization

Partial criteria list

Services and conditions requiring prior authorization (partial list from this section):

Abortion (pregnancy termination) — Prior authorization required; carved out by the state; contact the number on the back of the member's health plan ID card.

Acupuncture — Prior authorization required for listed CPT/HCPCS codes (e.g., 97811, 97814, S8930).

Bariatric surgery and specific obesity-related services — Prior authorization required for specified CPT codes (examples include 43644, 43775, 43847, 43645, 43842, 43659, 43845, 43860, 43770, 43846).

Behavioral health services — Prior authorization required; contact the number on the member's ID card or plan-designated behavioral health network for details and applicable codes.

Bone growth stimulators — Prior authorization required (example codes include 20975, 20979 where applicable).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Maryland

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number on the member's ID card.

SourceLink

On This Page

Cancer supportive care (outpatient colony-stimulating factors and bone-modifying agents) — Prior authorization required; enumerated J/Q codes (e.g., J1442, J2506, Q5101, etc.) require prior authorization for outpatient cancer diagnosis; submit via Provider Portal or call 888-397-8129.

Cardiology outpatient and office-based procedures (diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes) — Prior authorization required; use the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054; see Cardiology Prior Authorization and Notification Program for specific CPT codes.

Prior authorization coverage criteria (excerpt)

Prior authorization is required for the following categories and codes:

Injectable chemotherapy: Prior authorization required for outpatient injectable chemotherapy (intravenous, intravesical, intrathecal) for a cancer diagnosis; includes chemotherapy HCPCS range J9000-J9999 and specified codes such as J0640, J0641, J0642, J1950; also applies to Q-coded chemotherapy agents and miscellaneous HCPCS billed agents.

Injectable colony-stimulating factors: Numerous colony-stimulating factor J/Q codes (e.g., J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for outpatient administration for cancer supportive care.

Cochlear and auditory implants: Specific CPT/HCPCS device codes (e.g., 69710, 69711, 69714, 69930, L8614, L8619, L8627, L8628) require prior authorization via the Provider Portal or by phone (888-397-8129).

Continuous glucose monitors (CGM): CGM supplies and device HCPCS codes (e.g., A4226, A9278) require prior authorization; prior authorization is required with a type 2 diabetes diagnosis. Requests accepted via Provider Portal or 888-397-8129.

Reconstructive/cosmetic procedures: Certain reconstructive and cosmetic CPT codes listed in the document require prior authorization; consult the listed CPT codes in the policy and submit via Provider Portal or phone for authorization.

Durable medical equipment (DME): Extensive lists of E-, K-, V-, and other HCPCS codes require prior authorization as enumerated in the DME section; follow Provider Portal or phone guidance to obtain authorization.

Prior authorization code criteria (partial)

Services and codes listed below require prior authorization as noted.

Enteral in-home nutritional therapy (enteral/gastrostomy): Prior authorization required for listed B-series HCPCS codes (example: B4034 and related B-codes).

Experimental and investigational services: Prior authorization required for listed CPT/HCPCS/special codes (examples include 36514, 64722, 65765, 65767, 66180, A4638, A6000, E0231, E1831, S0810, S1030, S1031, S2102, S9988, S9990, S9991).

Femoroacetabular impingement (FAI) procedures: Prior authorization required for listed arthroscopic CPT codes (29914, 29915, 29916).

Functional endoscopic sinus surgery (FESS): Prior authorization required for listed FESS CPT codes (examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288).

Gender dysphoria-related procedures: Prior authorization required for the enumerated gender dysphoria surgical and procedural CPT/HCPCS codes when billed as listed; associated diagnosis codes F64.* and Z87.890 are referenced in the policy. Note: prior authorization may not be required when billed with specific diagnosis codes as noted elsewhere in the document.

Prior authorization criteria and exceptions (partial)

Prior authorization requirements and exceptions present in this section

Genetic and molecular testing (including BRCA) — Prior authorization required for the listed CPT/HCPCS/unique procedure codes (examples include 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81194, 81208, 81216, 81228, 81229, etc.).

Gender dysphoria treatment exception — Prior authorization not required when billed with specified diagnosis codes (diagnosis codes listed in the gender dysphoria section).

Providers requesting laboratory or molecular testing must complete prior authorization as indicated for many CPT codes; follow the listed codes and submission instructions in the policy.

Prior authorization required list

Items requiring prior authorization as listed

Enumerated chemotherapy, injectable medication, procedure, device and supply codes shown in the referenced sections require prior authorization; consult the code lists in the policy for the full enumerations (see injectable medications, J-codes, and DME lists).

Submission and special cases

Submission and special-case guidance

Submit prior authorization requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool (UHCprovider.com) or call 888-397-8129; for drugs without assigned codes billed under miscellaneous HCPCS or for newly marketed drugs, check the Review at Launch guidance and pre-determination is recommended.

Prior authorization criteria (codes and thresholds)

Services and codes requiring prior authorization in this section

Non-emergent air ambulance transport — Prior authorization required for HCPCS codes A0430 and A0431.

Maxillofacial/jaw functional impairment surgery — Prior authorization required for multiple 21xxx and 212xx CPT codes listed (examples include 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, etc.).

Orthotics and prosthetics (HCPCS L-codes) — Prior authorization required only for listed orthotics/prosthetic items when retail purchase or cumulative rental cost exceeds $500 (numerous L-codes enumerated in the policy).

Prior authorization requirements (partial)

Select services in this excerpt require prior authorization.

Examples

Private duty nursing — Prior authorization required (HCPCS T1002, T1003).
Potentially unproven services — Prior authorization required (examples include 33289, C2624, C2624).
Psychological testing — Prior authorization required; example CPT code 89240 and prior authorization may be required when billed with specified diagnosis codes as listed in the policy.

Prostate procedures — Prior authorization required for dates of service on or after April 1, 2022 for listed CPT codes (examples include 37243, 52441, 52442, 52442, 52442/55873, 53850).

Prior authorization requirements (partial list)

Prior authorization is required for the following services and in specified site-of-service circumstances:

Image-guided radiation therapy (IGRT) and advanced radiation therapy modalities — Prior authorization required for IGRT and mapped codes (examples include 77014, 77387, G6001, G6002 and related mappings); certain radiation therapy PA requirements may depend on diagnosis code ranges as indicated in the policy.

Advanced outpatient imaging procedures (selected CT, MRI, MRA, PET, nuclear medicine) — Prior authorization required; providers ordering advanced outpatient imaging must provide notification prior to scheduling and submit requests via the Prior Authorization and Notification tool (UHCprovider.com) or call 866-889-8054.

Rhinoplasty/septoplasty and shoulder surgery procedures — Prior authorization required for listed CPT codes (examples include rhinoplasty/septoplasty CPTs 30400–30465 range and shoulder arthroscopy CPTs such as 29805–29828 as indicated).

Prior authorization requirements (selected groups)

Procedures explicitly marked as requiring prior authorization:

Sleep apnea surgical procedures (maxillomandibular advancement and oral-pharyngeal tissue procedures) — Prior authorization required for listed CPT codes 21685, 41599, 42145.

Sleep studies

Diagnostic sleep study codes requiring prior authorization:

Polysomnography and related sleep study codes — Prior authorization required for CPT codes 95805, 95807, 95808, 95810, 95811.

Spinal surgery codes

Spinal surgery codes listed (prior authorization indicated):

Spinal surgery procedures — Prior authorization required for the enumerated spinal surgery CPT codes (examples include 22100, 22101, 22102, 22110, 22206, 22207, 22210, 22212, 22214, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819 and others listed).

Prior authorization coverage criteria (partial list)

Prior authorization is required for the following categories; contact instructions provided when available.

Stimulators / device implants: Prior authorization required for implantation of neurostimulators and bone growth stimulators; example device HCPCS/CPT codes include E0747, E0748, E0749, E0760 and L8682/L8685/L8686 where listed.

Transplants and CAR T-cell therapy: Prior authorization required for transplant services and CAR T-cell therapies (e.g., Kymriah, Yescarta); contact Optum Transplant Case Management at 888-936-7246 or use the number on the back of the member's ID card for authorization routing. Note: code 38232 requires prior authorization only when billed for an oncology diagnosis (see policy).

Vein procedures: Prior authorization required for listed vein procedure CPT codes (examples include 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766).

Ventricular assist devices (VAD): Prior authorization and notification required for VADs; call the notification number on the back of the member's ID card then fax the provided form to Optum VAD Case Management at 855-282-8929 (example codes: 33927, 33928, 33929, 33975, 33976, 33979, 33981–33983, Q0507–Q0509 as enumerated).

Wound VAC: Prior authorization required for wound VAC devices (example HCPCS code E2402).

38232 special rule: Code 38232 (hematopoietic progenitor cell collection) requires prior authorization only when billed for an oncology diagnosis (per policy note).

CPT / HCPCS / ICD-10 Code Lists

Injectable colony-stimulating factors and associated agentsHCPCSCovered

J1442	Filgrastim (Neupogen) - requires prior authorization
J2506	Pegfilgrastim (Neulasta) - requires prior authorization
Q5101	Zarxio biosimilar - requires prior authorization
J1449	Eflapegrastim (Rolvedon) - listed
J2820	Sargramostim (Leukine) - listed
J1447	Tbo-filgrastim (Granix) - listed
J0185	Antiemetic code listed (requires prior authorization)
J1456	Antiemetic drug code listed
J0885	Erythropoiesis-stimulating agent code listed
J1627	Listed (context: injectable medications section)

Breast reconstruction and bariatric surgery codesCPT | HCPCSCovered

19316	Breast reconstruction procedure code
19318	Breast reconstruction procedure code
11971	Breast-related procedure code
L8600	Breast prosthesis code
43644	Bariatric surgery code
43860	Bariatric surgery code

Injectable colony-stimulating factor related diagnosis codesICD-10

I70.739	ICD-10 code listed in colony-stimulating factor section
I70.741	ICD-10 code listed in colony-stimulating factor section
I72.3	ICD-10 code listed in colony-stimulating factor section

Chemotherapy injectable HCPCS/CPTHCPCSCovered

J9000-J9999	Chemotherapy injectable drug HCPCS range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional code listed)
J1950	Lupron Depot

Devices and suppliesHCPCS | CPTCovered

69710	Cochlear implant code
69711	Cochlear implant code
69930	Auditory implant related code
A4226	CGM supply HCPCS
A9278	CGM supply HCPCS

DME / miscellaneous HCPCS codesHCPCS

K0856	DME equipment code referenced in list
K0879	DME equipment code referenced
S1040	HCPCS code referenced
T1999	HCPCS code referenced
T5999	HCPCS code referenced
V2786	HCPCS code referenced

Example injectable/procedure codes (partial, fragmented list)CPT

64292

Genetic/molecular CPT codes requiring prior authorizationCPTCovered

81120	BRCA single site testing / example mapping in document
81479	Unlisted molecular pathology procedure (example present)

BiomarkersCPT

81538	Biomarker code listed
88299	Biomarker code listed

Selected injectable medication J-codesHCPCSCovered

J0801	Acthar Gel
J3262	Actemra
J0597	Berinert
J0178	Eylea
J1745	Remicade
J3399	Zolgensma

Procedures and service codes requiring prior authorizationCPT | HCPCS

G0156	Home health care (prior auth outpatient/home)
T2044	Hospice
58150	Hysterectomy
27120	Hip replacement
27447	Knee replacement

Air ambulanceHCPCSCovered

A0430	Non-emergent air ambulance transport
A0431	Non-emergent air ambulance transport

Maxillofacial surgery examplesCPTCovered

21121	Treatment of maxillofacial/jaw functional impairment
21206	Treatment of maxillofacial/jaw functional impairment

Orthotics & prosthetics (L-codes)HCPCSCovered

L0112	Orthotics/prosthetics example HCPCS L-code
L3976	Orthotics/prosthetics example HCPCS L-code

Sample HCPCS L-code group from excerptHCPCS

L6380	HCPCS L-code listed in colony-stimulating factors/orthotics section
L6590	HCPCS L-code listed
L6880	HCPCS L-code listed
L8040	HCPCS L-code listed

Therapy CPT codesCPT

92507	Speech/hearing therapy code listed
97110	Therapy CPT code listed multiple times
97113	Therapy CPT code listed

Nursing codesHCPCS

T1002	Private duty nursing
T1003	Private duty nursing

Pain management codesCPT

64493

Pain injection code

Psychological testing codesCPT

89240

Psychological testing code

Radiation therapy / IGRT codesCPT | HCPCSCovered

77014	Image-guided radiation therapy (IGRT) — mapping and PA note
77387	Intensity-modulated radiation therapy (IMRT) / IGRT mapping and PA note
G6001	IGRT related HCPCS code shown with PA requirement
G6002	IGRT related HCPCS code shown with PA requirement

Procedural codes requiring PACPTCovered

29805-29828	Range of arthroscopy shoulder procedure CPT codes referenced with PA required
31295-31298	Sinuplasty CPT codes — prior authorization required
30400-30462	Rhinoplasty and septoplasty CPT codes — prior authorization required
65710, 66821, 66982, 66984, 66987	Cataract/eye related CPT codes listed for PA

Sample codes by specialtyCPT

67010	Ophthalmologic procedure (example code listed)
29881	Arthroscopy/orthopedic procedure (example code listed)
22514	Spinal fusion procedure (noted with asterisk in source)

Sleep study codesCPTCovered

95810

Polysomnography with full monitoring

Selected procedure and device codesmixedCovered

63042	Spinal surgery related CPT (listed among many)
63272	Spinal surgery CPT
0098T	Spinal surgery/research tracking code
E0747	Implantable bone growth or stimulator equipment
38232	Hematopoietic progenitor cell collection — PA only for oncology diagnosis
Q2053	Pharmacy/biologic related HCPCS
36473	Vein procedure CPT
33927	VAD implantation/related CPT
E2402	Wound VAC

Prior authorization required for genetic/molecular testing

RequirementPrior authorization is required for genetic and molecular testing (including BRCA) as enumerated by the CPT/HCPCS and unique procedure codes listed in the policy (examples: 81120, 81121, 81162, 81163, 81164, 81165, 81208, 81216, 81228, 81229, 81479, etc.).

ScopeApplies to genetic and molecular tests performed in the outpatient and inpatient settings when the listed CPT/HCPCS codes are used; care providers requesting these laboratory tests must complete the prior authorization process.

Examples of covered codesExamples of CPT/HCPCS codes requiring prior authorization include 81120, 81121, 81162, 81163, 81164, 81165, 81208, 81216, 81228, 81229, 81479.

Submission methodSubmit requests via the Prior Authorization and Notification tool on UHCprovider.com or follow the call instructions referenced in the policy for phone-based submission.

Related guidanceRefer to the policy's 'Review at Launch for New to Market Medications' guidance and the full code lists in the policy for the most up-to-date inclusion of new molecular tests.

Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization is required for orthotics and prosthetics listed in the policy only when the retail purchase price or the cumulative rental cost exceeds $500.

Applies toHCPCS L-series orthotics and prosthetic codes enumerated in the policy (multiple L-codes shown in the document).

ExamplesSample L-codes listed in the policy include L0112, L0462, L0480, L0631, L6930, L7007 and many others; the threshold rule (>$500) governs authorization requirement.

ActionIf retail purchase or cumulative rental cost is over $500, obtain prior authorization per the policy instructions before claim submission.

How to requestUse the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or follow the phone instructions included in the policy to request authorization.

How Providers Submit Prior Authorization Requests & Key Operational Steps

Prior Authorization

Submit PA requests via UHCprovider Portal or member ID phone number

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using your One Healthcare ID and password; select the Prior Authorization and Notification tab. If you do not have a One Healthcare ID, visit UHCprovider.com/access. For assistance or alternate submission, call the number on the member’s ID card. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for non-emergent services.

Prior Authorization

PA required for cancer supportive care (colony‑stimulating factors, bone‑modifying agents)

Prior authorization is required for outpatient colony‑stimulating factor drugs and bone‑modifying agents used for cancer supportive care. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by calling 888-397-8129.

Prior Authorization

Cardiology outpatient/office procedures require PA

Cardiology outpatient and office‑based diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echocardiograms require prior authorization. Use the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054 and follow the Cardiology Prior Authorization and Notification Program for specific CPT codes.

Prior Authorization

Outpatient injectable chemotherapy requires PA

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) for a cancer diagnosis. Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 to obtain authorization.

Prior Authorization

CGM devices require PA (PA required with type 2 diabetes)

Continuous glucose monitors (CGM) require prior authorization and PA is required when billed with a type 2 diabetes diagnosis. Submit PA requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129.

Example HCPCS codes listed: A4226, A9278, A4239, A9276, A9277

Prior Authorization

Cochlear and auditory implants require PA

Cochlear and other auditory implants require prior authorization. Submit requests through the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by calling 888-397-8129.

Example CPT/HCPCS codes listed: 69710, 69711, 69714, 69930; L8614, L8619, L8627, L8628

Prior Authorization

DME items listed require PA

Durable medical equipment (DME) codes enumerated in the DME sections require prior authorization. Submit DME prior authorization requests using the Prior Authorization and Notification tool on UHCprovider.com or by calling 888-397-8129.

Examples of listed DME/HCPCS: A9279, E0265, E0300, E0457, E0470, E0620 (and many additional K‑ and E‑series codes)

Prior Authorization

Enteral in‑home nutritional therapy requires PA

Enteral in‑home nutritional therapy (enteral feeding or via gastrostomy) requires prior authorization for the listed B‑codes. Submit requests via the UnitedHealthcare Provider Portal or call 888-397-8129.

Example HCPCS: B4034

Prior Authorization

Experimental/investigational services require PA

Services designated as experimental or investigational require prior authorization for the listed CPT/HCPCS codes. Refer to the enumerated codes in the Experimental/Investigational section and submit PA requests via the Provider Portal or call 888-397-8129.

Example codes listed: 33477, 36514, 64722, 65765, A4638, A6000, E0231

Prior Authorization

FAI arthroscopic procedures require PA

Femoroacetabular impingement (FAI) arthroscopic procedures (codes 29914, 29915, 29916) require prior authorization. Use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call the number provided to request authorization.

FAI CPT codes: 29914, 29915, 29916

Prior Authorization

FESS procedures require PA

Functional endoscopic sinus surgery (FESS) CPT codes listed (e.g., 31240, 31253–31259, 31267, 31276, 31287, 31288) require prior authorization. Submit PA requests through the UnitedHealthcare Provider Portal or call 888-397-8129.

Example FESS codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288

Prior Authorization

Gender dysphoria procedures require PA (with specified Dx codes)

Gender dysphoria‑related surgical and procedural codes require prior authorization when billed with the associated diagnosis codes (F64.* or Z87.890). Follow the listed CPT/HCPCS code requirements and submit PA via the Provider Portal or phone.

Diagnosis codes referenced: F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890

Prior Authorization

Injectable chemotherapy drugs and listed codes require PA

Numerous injectable chemotherapy drugs and related HCPCS/CPT codes require prior authorization; consult the enumerated drug and code lists in the policy. Submit requests using the Prior Authorization and Notification tool on UHCprovider.com or by calling 888-397-8129.

Includes chemotherapy HCPCS range J9000–J9999 and specified codes such as J0640–J0642, J1950; Q‑codes and miscellaneous HCPCS as noted.

Prior Authorization

Genetic/molecular testing (BRCA and others) requires PA

Genetic and molecular testing (including BRCA testing) requires prior authorization for the enumerated CPT/HCPCS and unique procedure codes. Providers requesting these laboratory tests must complete the prior authorization process as indicated.

Example CPT codes listed: 81120, 81121, 81162, 81163, 81164, 81165, 81208

Documentation Required

Gender dysphoria treatment exception — PA not required with specified Dx codes

Prior authorization is not required for gender dysphoria treatment when billed with specified diagnosis codes listed in the policy; review the Gender Dysphoria section for the exact diagnosis codes and instructions.

Policy states: “Prior authorization not required when billed with the following diagnosis codes” (see Gender Dysphoria section for full list).

Prior Authorization

Primary PA submission methods: Provider Portal or 888‑397‑8129

For prior authorization you may submit requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or call 888-397-8129 for assistance.

Prior Authorization

Inpatient stays and selected outpatient services require PA

Prior authorization is required for all inpatient stays and for selected outpatient services (for example, home health care in outpatient/home settings and hospice). Providers must obtain authorization before claims submission for these services.

Home health care codes noted (outpatient/home): G0156, G0162, G0299, G0300; Hospice codes: T2044, T2045

Prior Authorization

Documented injectable chemotherapy codes require PA (see code lists)

Injectable chemotherapy drugs and related entries across the document are flagged as requiring prior authorization; consult the adjacent code listings for the specific HCPCS/CPT codes and submit PA via portal or 888-397-8129.

Prior Authorization

Hearing aids, home health, hospice, hysterectomy and infertility require PA

Various services such as hearing aid services, home health care (outpatient/home), hospice, hysterectomy and infertility procedures require prior authorization as indicated in the policy. Use the Provider Portal or listed phone numbers to submit requests.

Hearing aid example codes: V5171, V5172, V5181; Home health example codes: G0493–G0496; Hospice: T2044

Prior Authorization

Non‑emergent air ambulance (A0430, A0431) requires PA

Non‑emergent air ambulance transport requires prior authorization for HCPCS codes A0430 and A0431. Submit PA requests using the Provider Portal per the policy instructions.

Codes: A0430, A0431

Prior Authorization

Maxillofacial/jaw functional impairment surgery requires PA

Surgical treatment of maxillofacial/jaw functional impairment requires prior authorization for multiple CPT codes in the 21xxx and 212xx series; refer to the enumerated code list and obtain authorization prior to scheduling.

Example CPTs include: 21121, 21122, 21123, 21125, 21127, 21141–21147, 21150–21155, 21206, 21208–21210, 21215

Billing Rule

Orthotics/prosthetics L‑codes require PA when cost > $500

Orthotics and prosthetics L‑series HCPCS codes listed require prior authorization only when the retail purchase or cumulative rental cost is more than $500. Check the policy’s L‑code list and obtain PA when cost exceeds the $500 threshold.

Threshold: retail purchase or cumulative rental cost > $500
Examples of L‑codes listed in the policy: L0112, L0462, L0638, L6380, L6590

Prior Authorization

Outpatient therapy PA required for members ≥21 years

Outpatient therapy CPT codes listed require prior authorization for members age 21 and older. Review the therapy CPT list (e.g., 92507, 92508, 92526, 92630, 92633) and submit PA as required.

Therapy CPT examples: 92507, 92508, 92526, 92630, 92633

Prior Authorization

Private duty nursing requires PA

Private duty nursing services (HCPCS T1002, T1003) require prior authorization prior to service delivery. Submit PA via the Provider Portal per the policy instructions.

Codes: T1002, T1003

Prior Authorization

Pain injections require PA

Pain injections and management procedures are marked as requiring prior authorization; check the specific CPT entries in the policy (e.g., 64493) and obtain authorization before performing services.

Example pain injection code: 64493

Prior Authorization

Psychological testing requires PA (Dx‑dependent)

Psychological testing requires prior authorization, and PA may be required when billed with certain diagnosis codes; the policy lists CPT code 89240 as an example and indicates required PA when specific Dx codes are present.

Example code: 89240; PA required when billed with specified diagnosis codes (see policy)

Prior Authorization

HCPCS L‑codes listed require PA per enumerated list

Many HCPCS L‑series codes (orthotics/prosthetics and colony‑stimulating factor‑related L‑codes) are enumerated with instructions indicating prior authorization requirements; follow the listed codes and submit PA via the Provider Portal.

Representative L‑codes in the list include: L6380, L6590, L6686, L8040, L8610

Prior Authorization

Potentially unproven services require PA

Potentially unproven services identified in the policy require prior authorization; consult the codes listed (for example 33289, C2624) and obtain PA before furnishing these services.

Example codes: 33289, C2624

Prior Authorization

Prostate procedures require PA for DOS on/after 2022‑04‑01

Prostate procedures listed require prior authorization for dates of service on or after April 1, 2022; review the policy’s prostate procedure code list (e.g., 37243, 52441, 52442, 53850) and obtain authorization accordingly.

Effective note: PA required for specified prostate procedure dates of service on/after April 1, 2022
Example codes: 37243, 52441, 52442, 53850

Prior Authorization

Online PA submission workflow for radiology (Portal instructions)

To submit an online prior authorization request for radiology, sign in at UHCprovider.com, access the Prior Authorization and Notification tool, select the 'Radiology, Cardiology, Oncology and Radiation Therapy' box and choose 'Commercial' as the product type to be directed to the processing site.

Prior Authorization

Advanced outpatient imaging requires prior notification and PA

Care providers ordering advanced outpatient imaging procedures (certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology) are responsible for providing notification prior to scheduling and must submit prior authorization via the Provider Portal or call 866-889-8054.

Prior Authorization

IGRT and advanced radiation therapy require PA

Prior authorization is required for Image‑Guided Radiation Therapy (IGRT) and related advanced radiation therapy codes (e.g., 77014, 77387, G6001, G6002). Submit PA via the Provider Portal as directed in the IGRT/Radiation Therapy instructions.

IGRT example codes: 77014, 77387, G6001, G6002

Prior Authorization

Sleep apnea surgeries require PA

Sleep apnea procedures and surgeries (e.g., maxillomandibular advancement and oral‑pharyngeal tissue procedures) require prior authorization; referenced CPT examples include 21685, 41599 and 42145.

Example codes: 21685, 41599, 42145

Prior Authorization

Sleep studies (polysomnography) require PA

Diagnostic sleep studies (polysomnography) require prior authorization for the listed CPT codes (e.g., 95805, 95807, 95808, 95810, 95811). Obtain authorization via the Provider Portal before scheduling.

Sleep study CPTs: 95805, 95807, 95808, 95810, 95811

Prior Authorization

Spinal surgery codes require PA

Spinal surgery codes enumerated in the policy require prior authorization. Review the listed CPT codes (examples include 22100–22102, 22110, 22510–22515, 22600 series, 22800 series) and obtain PA prior to performance.

Representative spinal surgery CPTs: 22100, 22101, 22102, 22110, 22510–22515, 22600, 22800 series

Documentation Required

Confirm site‑of‑service (SOS) — may affect authorization routing

Some procedures include site‑of‑service (SOS) designations (for example outpatient or outpatient hospital) which may affect authorization routing; confirm SOS and follow the policy’s routing instructions when submitting prior authorization requests.

Prior Authorization

Neurostimulator and bone growth stimulator implants require PA

Implantation of neurostimulators and bone growth stimulators requires prior authorization; the policy lists device and procedure codes (for example E0747–E0760, L8682, L8685) and indicates PA is required for these implants.

Example device codes: E0747, E0748, E0749, E0760; example L‑codes: L8682, L8685

Prior Authorization

Transplant and CAR T therapy require PA — contact Optum Transplant Case Management

Transplant and CAR T‑cell therapy services require prior authorization; for these services (including Kymriah and Yescarta) call Optum Transplant Case Management at 888-936-7246 or use the number on the back of the member’s ID card. Note code 38232 requires PA only when billed for an oncology diagnosis.

Optum Transplant Case Management: 888-936-7246
Special rule: CPT 38232 requires PA only for oncology diagnoses

Prior Authorization

VAD implantation requires PA and notification to Optum VAD Case Management

Ventricular assist devices (VAD) require prior authorization and notification. Call the notification number on the back of 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.

Optum VAD Case Management fax: 855-282-8929

Prior Authorization

Vein procedures (saphenous ablation/removal) require PA

Vein procedures (including ablation/removal of saphenous trunks and branches) require prior authorization. Refer to the policy’s listed CPT codes (e.g., 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766) and obtain PA prior to treatment.

Example codes: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766

Prior Authorization

Wound VACs (e.g., E2402) require PA

Wound VAC therapy requires prior authorization; the policy lists E2402 as an example HCPCS code that requires PA. Submit authorization requests via the Provider Portal.

Example HCPCS: E2402

Note

Definitions and Clarifying Notes

Prior authorization required unless emergency or urgent care

DefinitionPrior authorization is required for services listed in this document except in cases of emergency or urgent care, which are exempt.

ScopeApplies to participating UnitedHealthcare Community Plan of Maryland providers for inpatient and outpatient services; out-of-network providers must request prior authorization for non-emergent services.

Submission methodsRequests may be submitted online using the Prior Authorization and Notification tool on UHCprovider.com or via the phone numbers provided in the policy.

State carve-out for abortion (pregnancy termination)

State carve-outAbortion (pregnancy termination) is carved out by the state; follow the carve-out instruction to contact the number on the back of the member's health plan ID card for authorization or guidance.

ActionCall the number on the member's ID card to obtain authorization instructions for abortion services per the state carve-out.

NoteAlthough the policy lists other services requiring prior authorization, abortion services are governed by the state carve-out instruction provided.

Injectable chemotherapy prior authorization (outpatient)

RequirementPrior authorization is required for outpatient injectable chemotherapy drugs (including intravenous, intravesical and intrathecal) when billed for a cancer diagnosis; includes J9000–J9999 range and specific codes such as J0640, J0641, J0642, J1950.

ExamplesPolicy examples include chemotherapy injectable drugs billed under J9000–J9999, leucovorin (J0640), levoleucovorin (J0641/J0642) and Lupron Depot (J1950).

SubmissionUse the Prior Authorization and Notification tool on UHCprovider.com or call the phone number provided in the policy (e.g., 888-397-8129) to request authorization.

Provider Portal authorization method

Primary methodUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) to submit prior authorization requests; sign in with One Healthcare ID.

Phone optionAlternatively, call the phone numbers provided in the policy for specific programs (examples include 888-397-8129 for general prior authorization and 866-889-8054 for radiology).

Out-of-network instructionOut-of-network providers must request prior authorization for non-emergent services per the policy guidance.

Prior authorization required

DefinitionPrior authorization required: Services and the CPT/HCPCS codes listed in the policy require approval prior to claim submission.

ImplicationProviders must obtain authorization before scheduling or performing non-emergent services identified in the code lists to avoid denials.

ExamplesThe requirement encompasses a wide range of services including enteral therapy, experimental/investigational procedures, FAI, FESS, and many device implant and procedural codes listed throughout the document.

Genetic and molecular testing prior authorization

RequirementGenetic and molecular testing (including BRCA testing) requires prior authorization when billed using the enumerated CPT/HCPCS and unique procedure codes in the policy.

Examples of listed itemsPolicy lists numerous codes (e.g., 81120, 81121, 81162, 81163, 81208, 81216, 81228, 81229, 81479 and many more) that require prior authorization for molecular/genetic testing.

Provider actionCare providers requesting laboratory genetic/molecular testing must complete the prior authorization process via the Provider Portal or the phone numbers specified in the policy.

Gender dysphoria treatment exception

ExceptionPrior authorization is not required for gender dysphoria treatment when the service is billed with the specified diagnosis codes listed in the policy (references include F64.* and Z87.890 and other Dx codes noted in the gender dysphoria section).

ScopeThis exception applies to the gender dysphoria-related surgical and procedural codes when the appropriate diagnosis codes accompany the claim.

Provider noteWhen billing gender dysphoria treatment with the listed diagnosis codes, providers do not need to obtain prior authorization per the policy statement; otherwise, prior authorization applies as noted for listed procedures.

Review at Launch for New to Market Medications policy

GuidanceRefer to the policy's 'Review at Launch for New to Market Medications' for pre-determination and the most current inclusion of newly approved drugs that may require prior authorization; pre-determination is highly recommended for drugs on the Review at Launch list.

ActionCheck the Review at Launch Medication List in the policy to confirm whether new drugs require prior authorization prior to prescribing or billing.

ContextThe policy explicitly directs providers to the Review at Launch resource for up-to-date information on new-to-market medications and associated prior authorization requirements.

Orthotics and prosthetics prior authorization threshold

ThresholdPrior authorization is required for orthotics and prosthetic HCPCS L-codes listed in the policy only when the retail purchase price or cumulative rental cost exceeds $500.

Applies toNumerous L-series HCPCS codes are enumerated throughout the policy; the $500 threshold determines whether prior authorization is necessary for those items.

Provider actionWhen the item’s retail purchase cost or cumulative rental cost is more than $500, submit a prior authorization request via the Provider Portal or follow the phone submission instructions in the policy before dispensing or billing.

Orthotics and prosthetics (section header and L-code listing)

SectionOrthotics and prosthetics — section lists many L-series HCPCS codes and indicates prior authorization requirements and related instructions for those codes.

ContentThe section enumerates numerous L-codes (examples include L6930, L6940, L6950, L7007, L7008, L8045) and provides the $500 retail/rental threshold rule that governs prior authorization for orthotic and prosthetic items.

Provider noteReview the L-code listings in this section to determine whether an orthotic/prosthetic item requires prior authorization under the policy's threshold rule.

Psychological testing prior authorization

RequirementPsychological testing requires prior authorization as indicated in the policy; authorization may also be required when tests are billed with specific diagnosis codes.

Example codeThe policy lists CPT/HCPCS code 89240 in the psychological testing entry and notes prior authorization is required when billed with certain Dx codes.

Provider actionWhen ordering psychological testing, verify if the diagnosis code on the claim triggers the prior authorization requirement and submit via the Provider Portal or contact the phone number in the policy.

Prior Authorization and Notification tool (UHCprovider.com)

Tool namePrior Authorization and Notification tool on UHCprovider.com (UnitedHealthcare Provider Portal).

How to accessSign in to UHCprovider.com using One Healthcare ID, select the Prior Authorization and Notification tab to submit requests online.

Phone alternativesWhere applicable, the policy provides program-specific phone numbers (examples: 888-397-8129 for general authorization; 866-889-8054 for radiology).

IGRT (Image-guided radiation therapy)

DefinitionIGRT (Image-guided radiation therapy) — includes codes such as 77014, 77387 and HCPCS G6001/G6002; IGRT and other advanced radiation therapy modalities require prior authorization as noted in the policy.

Code mappingPolicy maps IGRT codes (77014, 77387, G6001, G6002) to various modalities including IMRT and proton beam therapy and specifies prior authorization requirements tied to diagnosis code ranges for standard radiation therapy.

Provider actionSubmit prior authorization for IGRT and related radiation therapy codes via the Provider Portal or follow the radiology authorization instructions in the policy.

Site of service (SOS)

TermSite of service (SOS) — indicates outpatient or outpatient hospital designations that may affect authorization routing and requirements for certain procedures.

ImplicationSome CPT/HCPCS codes include SOS designations; verify site-of-service when determining authorization routing per policy instructions.

ExampleThe policy includes SOS notes for certain ophthalmologic and gynecologic procedure codes and indicates SOS may alter how authorization is processed.

Ventricular assist device (VAD)

DefinitionVentricular assist device (VAD) — a mechanical pump that takes over the function of a damaged ventricle; prior authorization and specific notification procedures are required.

How to obtain authorizationCall the notification number on the back of the member's health plan ID card, then fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.

Related devicesDevice implantation (neurostimulators, bone growth stimulators) and other major implants also require prior authorization as listed in the policy.

Stimulator (implantable device)

DefinitionStimulator (implantable device) — includes neurostimulators and bone growth stimulators; implantation procedures require prior authorization and are listed with example codes (e.g., E0747, E0748, E0749, E0760).

ExamplesPolicy lists device-related codes such as E0747, E0748, E0749, E0760 and related CPT entries tied to prior authorization requirements for device implantation.

Provider actionObtain prior authorization via the Provider Portal or follow the device-specific authorization instructions in the policy before implantation.

CAR T-cell therapy

DefinitionCAR T-cell therapy — cellular immunotherapy examples include Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel); these services require prior authorization and specialty routing.

How to obtain authorizationFor transplant and CAR T-cell therapy services, call the Optum Transplant Case Management team at 888-936-7246 or use the number on the back of the member's health plan ID card.

Special ruleSome hematopoietic/progenitor cell codes (example: 38232) require prior authorization only when billed for an oncology diagnosis; review the policy notes for code-specific rules.

OpenPayer

Related Billing Codes

Prior authorization requirements for UnitedHealthcare Community Plan of Maryland

Services and Conditions Requiring Prior Authorization

CPT / HCPCS / ICD-10 Code Lists

How Providers Submit Prior Authorization Requests & Key Operational Steps

Definitions and Clarifying Notes