CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for UnitedHealthcare

Lists prior authorization review requirements and submission methods for participating UnitedHealthcare commercial plan providers for inpatient and outpatient services; includes examples of services and codes that require prior authorization and notes on site-of-service and state exceptions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material changes — new effective date only

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or 24/7 chat.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

online/chatsubmission methods

exemptemergency/urgent care

SOS reviewsite-of-service review

>$1,000threshold

supportive care agentscancer supportive agents

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

multiplecodes listed

Coverage criteria and service groups requiring prior authorization

Colony-stimulating factors / bone-modifying agents — cancer supportive care

Covered when ALL of the following are met:

ALL of the following

Agent is administered in an outpatient setting
Diagnosis is cancer (oncology) when applicable; some listed codes also require authorization for non-oncology diagnoses (see injectable medications section)

ALL of the following

Applies to listed HCPCS/CPT codes including J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125

Follow standard submission process using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

Bariatric surgery — Bariatric surgery and related services

Prior authorization required for bariatric procedures and related services:

ALL of the following

Examples include 43644, 43645, 43659, 43770-43775, 43842-43848, 43860, 43865, 43886-43888

Center of Excellence requirement applies for coverage in some situations and certain benefit plans may not cover bariatric services

Prior authorization must be obtained before scheduling the service

Arthroscopy — Arthroscopy / arthroplasty

Covered when ALL of the following are met:

ALL of the following

Examples include 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29843, 29871

Prior authorization is required for these arthroscopy codes in all states

Site-of-service will be reviewed as part of the prior authorization process except in AK, MA, PR, RI, TX, UT, VI and WI

Breast reconstruction — Breast reconstruction (non-mastectomy)

Prior authorization required when ALL of the following apply:

ALL of the following

Listed examples include CPT codes 15771, 19300, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19370, 19371, 19396 and HCPCS L8600

Prior authorization is obtained before the procedure unless an exempt diagnosis code applies (exempt diagnosis codes are listed elsewhere in the document)

Prior authorization criteria (partial) — Listed items and services that require prior authorization in this excerpt.

Prior authorization is required for the following listed medications and service categories:

Anti-emetics (examples)

Akynzeo (palonosetron/fosnetupitant) — J1454, J2469
Cinvanti (aprepitant) — J0185
Emend (fosaprepitant) — J1453, J1456
Sustol (granisetron ER) — J1627

Supportive agents / biologics (examples)

Denosumab (Prolia/Xgeva) — J0897

Chemotherapy injectables — Injectable chemotherapy drugs administered outpatient require prior authorization.

Prior authorization required when ALL of the following are true:

Medication is an injectable chemotherapy agent administered in an outpatient setting

Drug is billed under J9000–J9999 or specific codes such as J0640, J0641, J0642, J1950, J1952, J1932 or a Q-code/unassigned/miscellaneous HCPCS for chemotherapy agents

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal

Cosmetic and reconstructive procedures — Cosmetic and reconstructive procedures and related codes require prior authorization.

Prior authorization required for cosmetic and reconstructive procedures listed below:

Requested procedure is one of the cosmetic or reconstructive CPT/HCPCS codes enumerated in the policy (examples include 11960, 11970, 14020–14021, 14302, 15570, 15730, 15820–15823, 15830, 15847, 15877–15879, 21137–21139, 21230–21235, 21256, 21260–21263, 21267–21268, 21275, 21280, 21282, 21295, 21740–21743, 28344, 54400, 67901–67924, Q2026 and others)

Prior authorization is required for cosmetic/reconstructive procedures in all states; site-of-service will be reviewed for specific codes except in AK, MA, PR, RI, TX, UT, VI and WI

Exemption note: Some codes may be exempt from prior authorization when billed with specified diagnosis codes (exempt DX codes are listed elsewhere).

Congenital heart disease services — Congenital heart disease–related services require advance notification or prior authorization.

Advance notification or prior authorization is required for congenital heart disease–related services:

Service is related to congenital heart disease including pretreatment evaluation or listed procedures

Providers must obtain advance notification or prior authorization as directed (for advance notification call 888-936-7246 or the notification number on the member's ID card)

Associated CPT codes (examples) include 33250, 33251, 33254–33261, 33390–33391, 33404, 33414–33417, 33465, 33468, 33476, 33478, 33500–33507 and many others as listed in the policy

Devices and clinical trials — Other device and trial categories require prior authorization.

Prior authorization required for the device and clinical trial categories below:

Cochlear/auditory implants

Cochlear and other auditory implants require prior authorization
Associated codes include 69710, 69714, 69930 and multiple L-codes (e.g., L8619, L8690, L8691, L8692, L8614)

Services billed as clinical trials (example codes S9988, S9990, S9991) require prior authorization

Authorization criteria and process notes — Prior authorization/notification requirements and notes for listed services and codes

General prior authorization and process notes for listed services and codes:

Prior authorization is required for the listed procedure and device codes in this segment unless a specific exception is stated

DME and prosthetics thresholds

DME listed requires notification/prior authorization when retail purchase or cumulative rental cost exceeds $1,000
Prosthetic HCPCS codes require prior authorization only when retail purchase or cumulative rental cost is more than $1,000

Advance notification is required when referring members to an out-of-network provider for ESRD dialysis services (call 877-842-3210 for notification/prior authorization)

High-level prior authorization criteria (screening colonoscopy, gender dysphoria services)

High-level rules for screening colonoscopy and gender dysphoria services:

Screening colonoscopy

Screening colonoscopy codes G0105 and G0121 require prior authorization/notification; site of service may affect requirement
Submit prior authorization requests via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054

Gender dysphoria services: Notification or prior authorization is required for listed gender dysphoria procedure codes when submitted with diagnosis codes F64.x or Z87.890 (examples include 55970, 55980 and others)

Genetic/molecular testing prior authorization criteria

Genetic and molecular testing performed outpatient requires prior authorization:

Genetic and molecular tests performed in an outpatient setting require prior authorization and laboratory notification to UnitedHealthcare

Example CPT/HCPCS test codes

Examples include 81162–81164, 81228–81229, 81349, 81400–81408, 81410–81417, 81420, 81425–81427, 81431–81435, 81437, 81439–81441, 81443–81445, 81448–81451, 81455–81465, 81471, 81479 and additional U-/S-codes listed in the policy

Follow the genetic testing authorization process indicated in the policy (laboratory should notify UnitedHealthcare per instructions)

Surgery and infertility prior authorization criteria

Surgical and infertility services prior authorization rules:

Prior authorization is required for listed inpatient-only and outpatient procedures related to hysterectomy, abdominal/laparoscopic surgeries and infertility diagnostics/treatments

Hysterectomy

Inpatient vaginal hysterectomies require prior authorization (e.g., 58267, 58270, 58292, 58294)
Outpatient vaginal hysterectomies do not require prior authorization

Infertility diagnostic and treatment services (examples: 55870, 58321–58323, 58345, 58752, 58760, 58970, 58974, 58976, 76948, 89250–89260) require prior authorization

Partial coverage criteria (listing)

Partial listing of coverage and situational criteria (examples):

Some CPT/HCPCS codes require prior authorization only when paired with specific diagnosis codes or when provided at specified places of service (POS); examples include enzyme replacement therapies limited to POS 19 and 22

Infertility-related diagnosis codes (examples: N46.01, N46.021, N46.022, N46.023, N46.024, N46.025, N46.029, N46.11, N46.121, N46.122, N46.123, N46.124, N46.125, N46.129, N46.8, N46.9, N97.0–N97.2) are referenced for authorization conditions

Providers must check the policy for the specific CPT/HCPCS code and diagnosis combination to determine whether prior authorization is required

MRgFUS coverage conditions — MR-guided focused ultrasound (MRgFUS) treatment of uterine fibroid

MRgFUS (MR-guided focused ultrasound) for uterine fibroid — conditional coverage and required preconditions:

Procedure is MRgFUS to treat uterine fibroid (CPT 0071T or 0072T)

Prior authorization is required and coverage is limited to certain benefit plans subject to terms and conditions

Required conditions include: confirmation of member coverage, contracted facility and physician, member written consent acknowledging limited published evidence and agreement not to hold UnitedHealthcare responsible, and demonstrated physician/facility experience as determined by UnitedHealthcare

Inpatient/post-acute admission prior authorization — Post-acute inpatient admissions

Prior authorization and notification requirements for inpatient/post-acute admissions:

Prior authorization and notification of admission date are required for facilities providing post-acute inpatient services

Applies to acute care hospitals, acute inpatient rehabilitation, critical access hospitals and long-term acute care hospitals

Unproven/experimental services - prior authorization

Potentially unproven, experimental or investigational services:

Service/procedure is listed as potentially unproven/experimental/investigational in the policy (examples include CPT codes 26340, 33289, 33361–33366, 33369, 33477, 36514, 64722 and others)

Prior authorization is required before rendering these services

Inpatient/post-acute prior authorization and notification criteria

Prior authorization and notification requirements for select inpatient/post-acute services and equipment:

Potentially unproven services listed (e.g., CPT 26340, 33289, 33361–33369, 33477, 36514, 64722) require prior authorization

Prosthetic HCPCS codes listed require prior authorization only when retail purchase or cumulative rental cost exceeds $1,000

Radiation therapy (IGRT/IMRT/proton beam) CPT/HCPCS codes require prior authorization as listed (examples: 77014, 77385, 77386, 77387, G6015–G6017, G6001–G6002)

Voluntary notification: upon confirmation of pregnancy providers are requested to notify UnitedHealthcare for numerous ICD-10-CM pregnancy codes; notification does not imply coverage

Prior authorization criteria for listed services — Coverage stance and PA conditions for listed services

Coverage stance and site-of-service conditions for listed services:

Radiation therapy (including IGRT, IMRT, proton beam) requires prior authorization when billed with the listed CPT/HCPCS codes

Sinuplasty CPT codes 31295–31298 require prior authorization

Rhinoplasty CPT codes (30410, 30420, 30430) require prior authorization for participating physicians; submit PA via Provider Portal or call 866-889-8054

Site-of-service rules: PA required when services are requested in an outpatient hospital setting or ASC for specified CPTs; PA may not be required if performed at a participating provider or in certain states as noted

Outpatient hospital prior authorization code list (partial)

Partial outpatient hospital code list — selected CPT/HCPCS codes shown that require prior authorization at the outpatient hospital site of service:

This block is a partial continuation of extensive outpatient-hospital CPT/HCPCS code listings in the policy; providers must refer to the full policy for specific codes and requirements

Prior authorization coverage criteria

Prior authorization required for the following procedures, studies and devices:

Surgical treatment of obstructive sleep apnea (e.g., maxillomandibular advancement, oral pharyngeal tissue reduction) requires prior authorization for all states; site-of-service review applies to listed codes

Laboratory-assisted polysomnography (in-lab sleep studies) require prior authorization (examples: 95805, 95807, 95808, 95810, 95811); home sleep studies are excluded

Spinal cord stimulator implantation and related CPT/HCPCS codes require prior authorization for all states; site-of-service will be reviewed for many of these codes (state exceptions listed elsewhere)

Multiple spinal surgery CPT codes require prior authorization for all states as listed in the policy

Prior authorization requirements and workflows

Prior authorization requirements and special workflows:

Prior authorization is required for the listed CPT/HCPCS codes in this segment for all states; site-of-service will be reviewed for specified codes except in listed jurisdictional exceptions

Implantation of stimulators not related to the spine requires prior authorization; site-of-service review applies with state exceptions

Therapeutic radiopharmaceuticals require prior authorization; instructions for submission and predetermination are provided in the policy

Transplant and transplant-related services require prior authorization/notification prior to pre-treatment; special call-in workflows are listed

Ventricular assist devices (VAD) require prior authorization and follow a call/fax workflow to Optum VAD Case Management (call the notification number on the member's ID card and fax to 855-282-8929)

Operational prior authorization requirements (partial)

Operational prior authorization steps for Ventricular Assist Devices (VAD) and listed procedures:

Prior authorization is required for Ventricular Assist Devices (VAD)

Providers must call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929

Submit listed CPT codes for VAD procedures per payer process (examples include 33927–33929, 33975–33983)

Code lists and coding notes

Arthroplasty examplesCPTCovered

23470

Arthroplasty — example code listed

Selected injectable medications requiring prior authorizationHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J1627	Sustol (granisetron extended release)
J0897	Denosumab (Prolia/Xgeva)
J0885	Epoetin alfa

Anti-emetics requiring prior authorizationHCPCSCovered

J1454	Akynzeo (palonosetron/fosnetupitant)
J2469	Akynzeo (palonosetron/fosnetupitant)
J0185	Cinvanti (aprepitant)
J1453	Emend (fosaprepitant)
J1456	Emend (fosaprepitant)
J1627	Sustol (granisetron extended release)

Bone-modifying agents, ESAs, and colony-stimulating factorsHCPCSCovered

J0897	Denosumab (Prolia, Xgeva)
J0885	Epoetin Alfa
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)

EEG and monitoring codesCPT

95700	Inpatient video EEG
95711	Inpatient video EEG
95712	Inpatient video EEG
95713	Inpatient video EEG
95714	EEG monitoring codes
95720	Outpatient EEG (no prior auth required)
95722	Outpatient EEG
95724	Outpatient EEG
95726	Outpatient EEG

Cartilage implants and related codesCPT | HCPCSCovered

27412	Cartilage implant procedure
27415	Cartilage implant procedure
27416	Cartilage implant procedure
29866	Arthroscopic cartilage procedure
J7330	Prosthetic device HCPCS example

Clinical trials and CGMHCPCS | CPT

S9988	Clinical trial service code
S9990	Clinical trial service code
S9991	Clinical trial service code
A4226	CGM sensor
A4238	CGM supplies
A4239	CGM supplies

Selected CPT/HCPCS codes referencedmixed

67901	Ophthalmic procedure (example from list)
Q2026	Botulinum toxin (example HCPCS) — appears in cosmetic/reconstructive list
28344	Reconstructive/cosmetic procedure code

Selected DME HCPCS codesHCPCS

E0328	DME example listed
K0853	Compressor/lymphedema pump example

Diagnosis codes tied to exceptionsICD-10

C43.0	Melanoma diagnosis code family — used as exception examples
C44.01	Other malignant neoplasm codes referenced in diagnosis exceptions

Screening colonoscopy codesHCPCSCovered

G0105	Colonoscopy - screening (site of service may apply)
G0121	Colonoscopy - screening (alternate)

Genetic and molecular testing codesCPTCovered

81162-81479

Range of genetic and molecular testing codes including BRCA and other panels (many specific codes listed across chunks)

Surgical and infertility codesCPTCovered

58267-58554	Hysterectomy and abdominal/laparoscopic surgery codes listed
55870-58976	Infertility diagnostic and treatment codes listed

Abdominal/laparoscopic procedure codes (partial)CPT

58550	Abdominal and laparoscopic surgeries (listed in excerpt)
58552	Abdominal and laparoscopic surgeries (listed in excerpt)
58553	Abdominal and laparoscopic surgeries (listed in excerpt)
58554	Abdominal and laparoscopic surgeries (listed in excerpt)

Infertility procedure codes (partial)CPT

55870	Infertility diagnostic/treatment procedure (listed)
58321	Infertility diagnostic/treatment procedure (listed)
58322	Infertility diagnostic/treatment procedure (listed)
58323	Infertility diagnostic/treatment procedure (listed)

Injectable medications and J-codes (partial)HCPCS

J0256	Injectable medication code listed (alpha1-proteinase inhibitors)
J1437	Injectable medication code listed (anemia)
J1439	Injectable medication code listed (anemia)
J9376	Blood modifying agent (listed multiple times)
J0174	Specialty injectable listed
J1426	Specialty injectable listed
J2781	Complement inhibitor - ophthalmologic use
J0180	Enzyme replacement therapy code (listed)
J3385	Enzyme deficiency (Gaucher disease) injectable - POS constraints
J0885	Erythropoiesis stimulating agent

Colonoscopy/injectable HCPCSHCPCS

J7322	HCPCS code listed under colonoscopy screening/injectables
Q5124	HCPCS Q-code listed under colonoscopy screening

MRgFUS codesCPTCovered

0071T	MRgFUS CPT/HCPCS - treat uterine fibroid
0072T	MRgFUS CPT/HCPCS - treat uterine fibroid

Potentially unproven service codesCPTExperimental

26340	Listed as potentially unproven service
33361	Listed as potentially unproven service

Selected potentially unproven CPT codesCPT

26340	Listed as a CPT code requiring prior authorization (potentially unproven services)
33289	Listed as a CPT code requiring prior authorization (potentially unproven services)
33477	Listed as a CPT code requiring prior authorization

Prosthetic HCPCS codes (extensive list)HCPCS

L5010	Prosthetic HCPCS code listed for prior authorization consideration
L8042	Prosthetic HCPCS code listed

Pregnancy ICD-10 codes for voluntary notificationICD-10

O09.00	ICD-10-CM pregnancy-related code listed for voluntary notification
O09.01	ICD-10-CM pregnancy-related code listed for voluntary notification

Radiation therapy codesmixed

77014	IGRT CPT code listed for prior authorization
77385	IMRT CPT code listed for prior authorization

Example prosthetics L-codesHCPCSCovered

L6905	Prosthetic code listed
L6910	Prosthetic code listed
L6920	Prosthetic code listed

Radiation therapy codesmixedCovered

77014	IGRT imaging code
G6017	IGRT modifier/HCPCS
77387	Radiation therapy planning/verification
77385	IMRT planning
77386	IMRT planning (additional)

ENT / nasal / miscellaneous surgical codesCPTCovered

31295	Balloon sinuplasty, first sinus
31296	Balloon sinuplasty, each additional sinus
30435	Treatment of nasal functional impairment
30450	Septoplasty/enhancement
64721	Carpal tunnel release (example referenced)

sample codes from this segmentCPT

68815
28295
25605
27640

Spinal cord stimulator codesCPTCovered

63650	Spinal cord stimulator trial lead placement
63655	Spinal cord stimulator implantation
63685	Lead revision or replacement
L8679	Implantable neurostimulator, spinal cord (SCS) generator

Sleep study lab codesCPTCovered

95805	Polysomnography; sleep staging with 1-3 additional parameters
95811	Polysomnography with continuous positive airway pressure

Spinal surgery and related procedure codes (partial list)CPTCovered

22812	Spinal surgery / instrumentation
22818	Spinal surgery / instrumentation
22819	Spinal surgery / instrumentation
22830	Spinal surgery / instrumentation
63001	Spinal surgery procedures (laminotomy/laminectomy series listed)
63005	Spinal surgery

Stimulators and neurostimulator codesmixedCovered

E0747	Bone growth stimulator / external electrical stimulator
E0748	Bone growth stimulator
E0749	Bone growth stimulator
E0760	Bone growth stimulator
61863	Neurostimulator procedure code
64590	Neurostimulator-related code (asterisk noted)

Therapeutic radiopharmaceuticals and cellular/gene therapyHCPCSCovered

C9399	Unlisted therapeutic radiopharmaceuticals / cellular and gene therapy
J3392	Cellular and gene therapy drug code
J3393	Cellular and gene therapy drug code
A9513	Therapeutic radiopharmaceutical
A9590	Therapeutic radiopharmaceutical

Vein procedures (removal and ablation)CPTCovered

36470	Vein removal and ablation procedures
36474	Vein ablation
37243	Endovascular procedure for veins (examples listed)
37700	Treatment of named branches of saphenous veins

Transplant and transplant-related procedure codesCPTCovered

38240	Bone marrow transplant-related procedures
38241	Bone marrow transplant-related procedures
33940	Heart transplant-related code listed
50320	Kidney transplant code listed

Vein removal/ablation codesCPT

36474	Removal and ablation of the main trunks and (listed)
36475	Removal and ablation of the main trunks and (listed)
36476	Removal and ablation of the main trunks and (listed)
36478	Removal and ablation of the main trunks and (listed)
36479	Removal and ablation of the main trunks and (listed)

Saphenous/venous procedure codesCPT

37243	Endovascular procedures for named branches of the saphenous veins
37780	Referenced with saphenous vein treatment
37700	Referenced with saphenous vein treatment
37718	Referenced with saphenous vein treatment
37722	Referenced with saphenous vein treatment

Ventricular assist device (VAD) codesCPT

33927	Ventricular assist device related code
33928	Ventricular assist device related code
33929	Ventricular assist device related code
33975	Ventricular assist device related code
33976	Ventricular assist device related code
33979	Ventricular assist device related code
33981	Ventricular assist device related code
33982	Ventricular assist device related code
33983	Ventricular assist device related code

What providers must do — submission methods, notifications, and operational workflows

Prior Authorization

How to submit prior authorization requests

Prior authorization and notification requirements — providers must submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com; sign in with One Healthcare ID). For questions or when noted, providers may also call the listed phone numbers on the member’s ID card or the numbers below. Prior authorization is not required for emergency or urgent care.

Online: UHCprovider.com > Prior Authorization and Notification tool (Sign In with One Healthcare ID).
Call for general prior authorization: 866-889-8054.
Some programs use specialty or plan-specific phone numbers (see individual entries).

Prior Authorization

Injectable & supportive medication prior authorization

Certain injectable and supportive medications (including many anti-emetics, colony-stimulating factors, erythropoiesis-stimulating agents, bone‑modifying agents and select specialty drugs) require prior authorization. Cancer-supportive agents require prior authorization when administered in an outpatient setting for a cancer diagnosis; some agents also require prior authorization for non‑oncology diagnoses.

Definitions and operational notes

Emergency/urgent care exemption

Emergency/urgent care exemptionPrior authorization is not required for emergency or urgent care.

Provider submission methodsFor non‑emergent services, submit prior authorization requests via the Provider Portal (UHCprovider.com) or 24/7 chat as described in the policy.

Policy updatesThe prior authorization list changes periodically; providers should consult UnitedHealthcare Network News or the Provider Portal for updates.

Site-of-service review

Site-of-service review for arthroscopySite‑of‑service will be reviewed as part of prior authorization for the listed arthroscopy codes; exceptions apply in AK, MA, PR, RI, TX, UT, VI and WI.

Arthroscopy codes subject

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for UnitedHealthcare

Policy CodePolicy N/A

Change TypeNo material changes — new effective date only

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or 24/7 chat.

SourceLink

On This Page

Epoetin alfa — J0885

Eflapegrastim (Rolvedon) — J1449

Filgrastim (Neupogen) — J1442; filgrastim-aafi (Nivestym) — Q5110

Inpatient video EEG monitoring (e.g., 95700, 95711–95716, 95718) requires prior authorization; outpatient EEGs (e.g., 95720, 95722, 95724, 95726) do not

Injectable chemotherapy drugs administered in an outpatient setting require prior authorization (including J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642, leuprolide acetate J1950/J1952 and others)

Site-of-service will be reviewed as part of prior authorization for many codes; state exceptions include AK, MA, PR, RI, TX, UT, VI and WI

Setting-specific prior authorization requirement

Inpatient video EEGPrior authorization required for inpatient video electroencephalogram (cerebral seizure monitoring) (e.g., CPT 95700, 95711–95713).

Outpatient injectable chemotherapyPrior authorization required for injectable chemotherapy drugs administered in an outpatient setting (includes J9000–J9999 and specified supportive agents).

Outpatient EEGOutpatient EEGs (e.g., CPT 95720, 95722, 95724, 95726) do not require prior authorization.

DME purchase/rental cost threshold

DME cost thresholdPrior authorization/notification required only for DME codes listed with a retail purchase or cumulative rental cost greater than $1,000.

Cumulative rental noteSome DME entries reference cumulative rental cost as the trigger for authorization (see listed HCPCS examples such as E0328, E1002).

Prosthetics distinctionProsthetics are not considered DME; separate prosthetics threshold rules apply (see prosthetics section).

Setting requirement

Outpatient genetic/molecular testingPrior authorization is required for genetic and molecular testing performed in an outpatient setting (includes BRCA and many CPT/HCPCS codes such as 81162–81164, 81228–81229, 81400–81479, 81507, etc.).

Lab notificationLabs performing outpatient genetic/molecular testing should notify UnitedHealthcare per the instructions in the genetic testing section.

Submission guidanceUse the Provider Portal Prior Authorization and Notification tool to submit requests for outpatient genetic/molecular testing.

POS limitation

POS 19/22 limitationCertain enzyme replacement and multiple sclerosis injectable therapies are limited to POS 19 and 22 (outpatient hospital/ASC) and require prior authorization when provided in those settings.

Example enzyme replacementExample: enzyme deficiency therapy (e.g., J3385) is noted with POS 19 and 22 only in the injectable medications section.

Multiple sclerosis agentsMultiple sclerosis injectable medications listed in the policy are annotated as POS 19 and 22 only where indicated; prior authorization applies per entry.

Orthotics prior authorization threshold

Orthotics cost thresholdOrthotics require prior authorization only for codes listed with a retail purchase or cumulative rental cost greater than $1,000 (see L‑code examples in the orthotics list).

Applicable codesAuthorization applies only to the orthotics HCPCS codes enumerated in the orthotics section (e.g., L0482, L0484, L0486, L0636, etc.).

Cost basisThreshold is evaluated on retail purchase price or cumulative rental cost as specified in the orthotics entries.

Prosthetic prior authorization cost threshold

Prosthetics cost thresholdPrior authorization required only for prosthetic HCPCS codes listed with a retail purchase or cumulative rental cost greater than $1,000.

Separate from DMEProsthetics are treated separately from DME; the $1,000 threshold applies to prosthetic codes shown in the prosthetics list (extensive L‑code list provided).

Code examplesExamples of prosthetic HCPCS codes subject to this rule are included in the document (e.g., L5010, L8042, L7180 series).

38232 oncology-only prior authorization

Code 38232 — oncology-only PACPT 38232 requires prior authorization only when billed with an oncology diagnosis (PA not required for non‑oncology DX per note).

Related transplant codesThis note appears in the cellular and gene therapy/transplant section where marrow/transplant codes are listed; follow transplant PA workflows when applicable.

Submission instructionSubmit prior authorization requests for transplant‑related services via the Provider Portal or per transplant-specific instructions in the policy.

Anti-emetics requiring prior authorization: Akynzeo (palonosetron/fosnetupitant) J1454, J2469; Cinvanti (aprepitant) J0185; Emend (fosaprepitant) J1453/J1456; Sustol (granisetron ER) J1627.
Bone-modifying agent: Denosumab (Prolia, Xgeva) J0897.
Erythropoiesis-stimulating agent: Epoetin alfa J0885.
Colony-stimulating factors requiring prior authorization: eflapegrastim J1449; filgrastim J1442*; filgrastim biosimilars Q5110*, Q5125, etc.
Some codes (e.g., J1442, J1447, J2506, Q51xx series) also require prior authorization for non-oncology diagnoses — see injectable medication section.

Prior Authorization

ESRD dialysis services — notification/prior authorization

End-stage renal disease (ESRD) dialysis services require advance notification when members are referred to an out-of-network provider. Prior authorization may be required in certain situations per the member’s benefit plan.

For notification/prior authorization call: 877-842-3210.
Advance notification required when referring members outside the UnitedHealthcare network.
Prior authorization not required for ESRD when a member ... (follow plan-specific rules).

Prior Authorization

DME — prior authorization/notification and cost threshold

Durable medical equipment and certain orthotics/prosthetics require notification or prior authorization when the retail purchase or cumulative rental cost exceeds the threshold (typically > $1,000). A set list of DME/orthotic/prosthetic HCPCS codes are subject to prior authorization.

Notification/prior authorization required only for DME codes with a retail purchase or cumulative rental cost above the plan threshold (see code list).
Examples of DME codes that require review: A7026, E0194, E0265–E0266, E0277, E0296–E0297, E0300–E0304, E0328–E0329, E0466, E0471, E0483, E0745, E0764, E0766, E0770, E0784, E0984–E1006, E1007–E1010, E1016, E1018, E1236, E1238, E1399, E1830, E2402, E2502–E2510, etc.
Prosthetics require prior authorization only for listed codes with retail purchase or cumulative rental cost > $1,000 (see L-series code list).

Prior Authorization

GI endoscopy and related procedures — advance notification/prior authorization

Gastroenterology endoscopy procedures (EGD, colonoscopy, capsule endoscopy and many related CPT codes) have advance notification encouraged and prior authorization or site-of-service review may apply, particularly for screening colonoscopies depending on site of service.

Screening colonoscopy (lower GI) codes: G0105, G0121 — site-of-service review may apply.
Common colonoscopy CPTs noted for review: 45378*, 45379*, 45380*, 45381*, 45384*, 45385*, 45386*, 45390*, 45398* (asterisked codes indicate screening-related rules).
Submit prior authorization requests online via UHCprovider.com > Prior Authorization and Notification or call 866-889-8054.
Advance Notification is encouraged for participating providers; a site-of-service medical necessity review will be conducted if screening colonoscopy is performed in certain settings.

Prior Authorization

Foot surgery — prior authorization and site-of-service review

Foot surgery procedures require prior authorization in all states. For many foot surgery CPT codes the site of service will be reviewed as part of prior authorization (exceptions apply in certain states).

Prior authorization is required for all states for listed foot surgery codes (examples include 28285, 28289, 28291–28299, 28295, 28296–28299).
Site-of-service review applies for specified codes except in AK, MA, PR, RI, TX, UT, the Virgin Islands and WI.
Submit requests using the Provider Portal prior authorization tool or call the number on the member's ID card.

Prior Authorization

Colonoscopy screening prior authorization and submission instructions

Screening colonoscopy (lower gastrointestinal) — submit prior authorization requests online using the Prior Authorization and Notification tool on the Provider Portal. Site-of-service rules (SOS) may apply to screening colonoscopies.

Codes associated with screening colonoscopy include G0105, G0121 and many CPT colonoscopy codes (see Gastroenterology Endoscopy Advance Notification resource).
Please submit prior authorization requests online via UHCprovider.com (Sign In) > Prior Authorization and Notification tool, or call 866-889-8054.
A site-of-service medical necessity review will be conducted if a screening colonoscopy is performed in an outpatient hospital setting or ASC; office or ASC may be preferred depending on review.

Prior Authorization

Home health non-nutritional prior authorization

Home health (non-nutritional) services performed in outpatient settings, including the member's home, require prior authorization.

Home health non-nutritional codes: T1000, T1002, T1003 (and other listed HCPCS) require prior authorization when provided in outpatient/home settings.
Submit requests online via the Provider Portal or follow the plan-specific prior authorization instructions.

Prior Authorization

Conditional prior authorization based on DX

Some procedure codes require prior authorization only when billed with certain diagnosis codes; conversely, specific combinations of procedure and incontinence diagnosis codes may not require prior authorization.

The following codes require prior authorization only if the DX code meets specified criteria (examples listed in source): 52402, 54500, 54505, 55550, 58140, 58145, 58146, 58545, etc.
No prior authorization required for listed procedure + incontinence diagnosis code combinations (see ICD-10 codes N32.81, N32.9, N39.3, N39.41, N39.42, N39.46, N39.490, N39.498, etc.).
Check the diagnosis when submitting — authorization requirement may be conditional on DX.

Prior Authorization

MRgFUS for uterine fibroid — prior authorization and coverage conditions

MR‑guided focused ultrasound (MRgFUS) for uterine fibroid requires prior authorization and coverage is limited to certain benefit plans with specific conditions.

MRgFUS CPT/HCPCS: 0071T, 0072T.
Coverage conditions (typical): physician/facility must confirm member coverage; hospital/facility must be contracted with UnitedHealthcare; members generally have no out‑of‑network benefits for MRgFUS; member must consent in writing acknowledging limited evidence and agreeing not to hold UnitedHealthcare responsible if unsatisfied; physician and facility must demonstrate experience and follow U.S. FDA requirements.
Submit prior authorization via the Provider Portal or call 866-889-8054 as directed.

Prior Authorization

Non-emergency air transport — prior authorization

Non-emergency air (air ambulance) transport requires prior authorization.

Non-emergency air transport codes: A0430, A0431, A0435, A0436; S9960, S9961 for specified nonurgent air ambulance transports.
Prior authorization required before nonurgent ambulance/air transport.
Contact the Provider Portal or the phone number on the member’s ID card for authorization.

Prior Authorization

Prostate procedures — prior authorization

Prostate procedures listed require prior authorization.

Examples of prostate procedure CPTs requiring prior authorization: 52441, 52442, 53850, 55874 (and other listed codes).
Follow the Prior Authorization and Notification submission process via the Provider Portal or call the plan-specific number.

Prior Authorization

Prosthetics — prior authorization threshold and codes

Prosthetics require prior authorization only for the prosthetic codes listed when the retail purchase or cumulative rental cost is more than $1,000.

Examples of listed prosthetic HCPCS requiring prior authorization when > $1,000: L5010, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5230, L5250, L5270, L5280, L5301, L5321, L5331, L5400, L5420, and many additional L-codes in the source list.
Submit prior authorization requests via the Provider Portal and include cost/purchase vs rental details.

Note

Pregnancy — voluntary notification and codes

Pregnancy notification — providers are requested to voluntarily notify UnitedHealthcare upon confirmation of pregnancy to enable case and disease management enrollment and member support; a comprehensive list of relevant ICD‑10 codes is provided.

Voluntary notification allows UnitedHealthcare to enroll the pregnant member in case and disease management programs and provide resources (Pregnancy Program, Pregnancy app, Healthy Pregnancy resources).
Notify upon confirmation of pregnancy for ICD‑10 codes such as Z32.01, Z33.1, Z34.xx series, O09.xx and many related O30/O24/O26 codes (see full ICD‑10 list).
Notification does not imply coverage; submit only once per pregnancy.

Prior Authorization

Radiation therapy — prior authorization

Radiation therapy—including IGRT, IMRT, proton beam and associated specialized radiation procedures—requires prior authorization.

Radiation therapy codes that require prior authorization: IGRT 77014, G6017; 77387; IGRT/IMRT codes 77385, 77386, G6015, G6016; other G60xx codes as listed.
Therapeutic radiopharmaceuticals also require prior authorization (examples: A9513, A9590).
Submit prior authorization requests via UHCprovider.com > Prior Authorization and Notification or call the appropriate prior authorization number.

Prior Authorization

Rhinoplasty prior authorization

Rhinoplasty and related nasal functional procedures require prior authorization when applicable. Providers should submit requests via the Provider Portal or call the listed number.

Rhinoplasty CPTs include 30410, 30420, 30430, 30435, 30450, 30460, 30462 (as applicable) — prior authorization required for participating physicians requesting these procedures.
Submit prior authorization online via the Prior Authorization and Notification tool or call 866-889-8054.
Functional nasal/septal deviation procedures (e.g., 30435, 30450, 30460, 30462) have additional clinical criteria — include documentation of functional impairment.

Prior Authorization

Site-of-service prior authorization rules

Site-of-service (SOS) review rules: prior authorization is required when services (many procedural codes) are requested in an outpatient hospital setting or ambulatory surgery center; in many cases the preferred site is the office and SOS review is performed as part of prior authorization.

Site-of-service prior authorization required if performed in outpatient hospital or ASC for specified codes; office-based service may be preferred.
Certain codes are exempt from SOS review in AK, MA, PR, RI, TX, UT, the Virgin Islands and WI.
Examples of service groups subject to SOS review include arthroscopy, foot surgery, spinal stimulators, some implantable stimulators, and many listed outpatient hospital CPTs.

Prior Authorization

Outpatient hospital prior authorization codes (continued)

Extensive lists of outpatient hospital CPT/HCPCS codes across multiple systems require prior authorization. Providers should check the Provider Portal or the policy’s full code lists before scheduling or providing services.

Outpatient hospital codes across systems (musculoskeletal, cardiovascular, gastrointestinal, ENT, genitourinary, female/male genital systems, dermatologic, etc.) are included in the prior authorization lists — see the policy code sections (partial lists in this document include 150+ CPTs).
When requesting authorization for outpatient hospital procedures, include proposed place of service; site-of-service review may influence determination.
If a code is marked with SOS review or exceptions, follow the portal guidance and plan-specific instructions.

Prior Authorization

Outpatient hospital prior authorization codes (continued - multiple systems)

Additional outpatient hospital procedure code lists continue across multiple systems and are subject to prior authorization; a comprehensive review of the code lists should be performed prior to care delivery.

Further outpatient hospital CPT/HCPCS codes (continued) include many head/neck, thoracic, abdominal, musculoskeletal and reconstructive procedure codes — verify requirements on the Provider Portal.
Some codes require prior authorization in all states and include site-of-service review; others are conditional based on diagnosis or place of service.
Use the Prior Authorization and Notification tool on UHCprovider.com for submission and to view up-to-date code lists.

Prior Authorization

Outpatient hospital prior authorization codes (extensive continuation)

An extensive continuation of outpatient hospital CPT/HCPCS codes requiring prior authorization is provided in the policy (musculoskeletal, spine, reconstructive, vascular, etc.). Providers must consult the full code list when requesting authorization.

Large blocks of CPTs (e.g., 20000–29999, 30000–39999, 40000–69999 ranges highlighted in the policy) are included and subject to prior authorization — consult the policy for exact codes.
Spinal surgery, stimulators, and many implantable device procedures require prior authorization and often include SOS review.
Submit requests online via the Provider Portal and include clinical documentation to support medical necessity.

Prior Authorization

Sleep studies prior authorization

Laboratory‑assisted sleep studies (polysomnography) require prior authorization; home sleep studies are excluded from this requirement.

Sleep study CPTs requiring prior authorization include: 95807, 95808, 95810 (laboratory‑assisted polysomnography) and related codes; 95805 and 95811 referenced for other sleep procedure listings.
Home sleep testing is excluded from prior authorization requirement (confirm per plan policy).
Submit prior authorization requests via the Provider Portal for lab-based sleep studies.

Prior Authorization

Cellular and gene therapy and select codes

Cellular and gene therapies and select related codes require prior authorization. Code 38232 requires prior authorization only when billed for an oncology diagnosis.

Cellular and gene therapy codes subject to prior authorization include C9399, J3392–J3394, J3490, J3590 and Q20xx/Q205x Q-codes (see policy list).
Code 38232 requires prior authorization only for oncology diagnoses.
Submit prior authorization requests via the Provider Portal; for novel/new-to-market agents refer to Review at Launch guidance and consider predetermination.

Prior Authorization

VAD prior authorization contact procedure

Ventricular assist devices (VAD) require prior authorization and a notification process involving a call and fax to case management.

For VAD prior authorization, please call the notification number on the member’s ID card.
After calling, fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.
VAD CPT/HCPCS examples include 33927, 33928, 33929, 33975–33983 and others listed — prior authorization required.

Prior Authorization

Procedure codes requiring prior authorization (partial list)

Partial list of procedure codes requiring prior authorization is included throughout the policy — confirm each code and any diagnosis or site-of-service conditions prior to rendering services.

Many procedure CPT/HCPCS codes across specialties require prior authorization (see the policy sections for tables and code lists).
If a code is not listed or if clinical circumstances differ, providers should submit a predetermination/prior authorization request via the Provider Portal.
For specialty medications or complex services, follow specialty pharmacy or plan-specific submission instructions (tiles on the Provider Portal dashboard).

The arthroscopy codes listed include CPTs such as 29805, 29820, 29824, 29806, 29821, 29825, 29807, 29822, 29827, 29819, 29823 and 29828.

PA applies all statesPrior authorization required for these arthroscopy codes in all states; site‑of‑service review accompanies PA except in the listed jurisdictions.

Prior Authorization and Notification tool / phone numbers

Provider Portal submission (UHCProvider.com)Submit prior authorization and predetermination requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID.

24/7 chat optionProviders may also connect via 24/7 chat on the Contact Us page for certain submissions or inquiries.

Phone alternativesWhere noted, phone numbers are provided for specific programs (e.g., 888‑397‑8129, 866‑889‑8054) — see the relevant section for the correct contact.

Clinical trials

Clinical trials require PAServices billed as clinical trials (rigorously controlled studies) require prior authorization (example CPT/HCPCS: S9988, S9990, S9991).

Definition contextClinical trials are defined as rigorously controlled studies of a new drug, medical device or other intervention and are subject to PA per the policy.

Submit via PortalUse the Provider Portal Prior Authorization tool to submit PA requests for clinical trial‑related services.

Continuous Glucose Monitor (CGM)

CGM PA with type 2 diabetesContinuous glucose monitors require prior authorization when used with a type 2 diabetes diagnosis (HCPCS examples include A4226, A4238, A4239, A9276–A9278, E0787, E2102, E2103).

Listed HCPCS examplesHCPCS codes listed for CGM include A4226, A4238, A4239, A9276, A9277, A9278, E0787, E2102, E2103.

PA submissionSubmit PA requests for CGMs via the Provider Portal per the general submission instructions.

Cochlear and auditory implants

Cochlear and auditory implants require PACochlear and other auditory implants require prior authorization (codes include 69710, 69714, 69930 and L‑codes such as L8619, L8690, L8691, L8692, L8614).

Device descriptionThese implants include internal and external components to assist persons with profound sensorineural deafness.

Submission instructionSubmit PA requests for cochlear/auditory implants via the Provider Portal as directed in the devices section.

Prior authorization

Prior authorization general rulePrior authorization is required for the services and codes listed in this policy except where an exemption (e.g., emergency/urgent care) or specific exception is noted.

Site-of-service reviewSite of service will be reviewed as part of prior authorization for many codes; state exceptions are noted in the policy where applicable.

Use Provider PortalSubmit PA requests through UHCprovider.com unless an alternate workflow (phone/fax) is specified for a given service.

DME prior authorization/notification

DME PA tied to cost thresholdDME prior authorization/notification applies only to the DME codes listed and only when the retail purchase or cumulative rental cost exceeds the $1,000 threshold (examples provided in the HCPCS lists).

Examples of covered DMEDocument lists numerous DME HCPCS codes (e.g., E0328, E1002, E2502, K‑series codes) that are subject to the threshold rule.

Prosthetics noteProsthetics are addressed separately (see prosthetics section); some items may have different rules regardless of cost.

ESRD notification contact

ESRD advance notificationAdvance notification is required when members are referred to an out‑of‑network provider for ESRD dialysis services; call 877‑842‑3210 for notification/prior authorization.

Referral contextThis applies to outpatient dialysis services for treating end‑stage renal disease when referring members outside the UnitedHealthcare network.

Use specified contactUse the stated phone number (877‑842‑3210) for ESRD notification/prior authorization per the policy.

Prior Authorization / Notification

Submission methods — Provider Portal primaryPredetermination and prior authorization requests are to be submitted through the UnitedHealthcare Provider Portal (UHCprovider.com) using the Prior Authorization and Notification tool (Portal/Specialty Pharmacy tiles as appropriate).

Phone alternativesWhere provided, phone numbers may be used for program‑specific workflows (e.g., 866‑889‑8054); see the relevant section for correct contact information.

Chat option24/7 chat via the Contact Us page is available for certain inquiries and submissions as noted in the policy.

Genetic and molecular testing (outpatient)

Genetic/molecular testing (outpatient) PAGenetic and molecular testing (including BRCA) performed in an outpatient setting requires prior authorization and labs should notify UnitedHealthcare per instructions (many CPT/HCPCS/U‑codes listed).

Examples of codesExamples include 81162–81164, 81228–81229, 81400–81479, 81507, 81518–81522, 87505–87506 and others enumerated in the genetic testing lists.

Submission and lab notificationSubmit authorization requests via the Provider Portal; labs must follow the lab notification instructions noted in the genetic testing section.

POS / Site of Service

POS for certain injectables and devicesSite‑of‑service restrictions apply for certain procedures and injectables; for example, some enzyme replacement and multiple sclerosis therapies are limited to POS 19 and 22 as noted.

Cochlear/device PADevice submissions such as cochlear implants require prior authorization and include associated CPT/HCPCS codes; site‑of‑service review may apply.

Check code entriesRefer to the specific code entries for POS constraints and site‑of‑service instructions for each injectable or device category.

Prior authorization — service-level notes

Inpatient video EEG PAPrior authorization required for inpatient video EEG monitoring (cerebral seizure monitoring) — see CPT 95700, 95711–95713 entries.

Outpatient EEG not requiredOutpatient EEGs do not require prior authorization (CPT 95720, 95722, 95724, 95726 listed as outpatient codes).

Injectable chemo PAInjectable chemotherapy drugs administered outpatient require prior authorization — includes J9000–J9999 and specified supportive agents (see chemotherapy section).

MRgFUS coverage conditions

MRgFUS PA and coverage conditionsMR‑guided focused ultrasound (MRgFUS) to treat uterine fibroid requires prior authorization and is covered only for certain benefit plans with contractual and consent conditions (CPT 0071T, 0072T).

Member consent requirementsMember must consent in writing acknowledging limited published evidence and agree not to hold UnitedHealthcare responsible for dissatisfaction as part of coverage conditions.

Facility and provider requirementsPhysician/facility must confirm coverage, be contracted with UnitedHealthcare, and demonstrate experience/expertise as determined by UnitedHealthcare.

Unclassified/temporary code prior auth note

Unclassified/temporary code PA noteFor unclassified/temporary codes (C9399, J3490, J3590) prior authorization/notification is required only for specified products (e.g., Nulibry™, Ocrevus Zunovo™, Rivfloza™, Revcovi™).

Review at Launch guidanceConsult the Review at Launch for New to Market Medications policy and Review at Launch Medication List for newly approved drugs that may require predetermination.

Oncology/non‑oncology noteSome unclassified/temporary code entries require PA for both oncology and non‑oncology diagnoses or have oncology‑specific guidance; follow the code notes.

Potentially unproven services

Potentially unproven servicesPotentially unproven, experimental or investigational services listed require prior authorization (examples include CPT 26340, 33289, 33361–33366, 33369, 33477, 36514).

PA required prior to performancePrior authorization is required for these potentially unproven services as enumerated in the policy before scheduling or performing the service.

Refer to code listProviders must reference the listed CPT/HCPCS codes in the potentially unproven services section when submitting PA requests.

Prosthetics (prior authorization rule)

Prosthetics PA rulePrior authorization required only for prosthetic HCPCS codes listed with a retail purchase or cumulative rental cost greater than $1,000 (extensive L‑code list provided).

Extensive code listThe document provides an extensive list of prosthetic HCPCS codes (e.g., L5010, L5050, L8042, L7180 series) that are subject to the threshold rule.

Separate handling from DMEProsthetics are not DME and are handled under their own prior authorization threshold and code listings.

Voluntary notification — pregnancy

Voluntary pregnancy notificationProviders may voluntarily notify UnitedHealthcare upon confirmation of pregnancy to enroll members in case and disease management; a long list of ICD‑10‑CM pregnancy codes is provided for notification (notification does not imply coverage).

Notification purposeVoluntary notification enables case and disease management enrollment and does not itself determine coverage.

Code examplesThe policy lists numerous ICD‑10‑CM codes (e.g., O09.x series, O12.x, O21.x, O24.x, Z34.x, Z32.01) for which voluntary notification is requested.

Prior Authorization submission method

PA submission via Provider PortalPredetermination and prior authorization requests should be submitted via UHCProvider.com using the Provider Portal (Portal button / Specialty Pharmacy Transactions tile as appropriate).

Specialty Pharmacy tileUse the Specialty Pharmacy Transactions tile on the Provider Portal Dashboard when applicable for specialty injectable medication authorizations.

Portal support contactsRefer to the Portal help resources or the phone contacts listed in specific sections if you have questions about online submission workflows.

Site-of-service (SOS)

Site-of-service (SOS) rulesSite‑of‑service rules: Prior authorization is required when services are requested in an outpatient hospital setting or ASC for specified CPTs; PA may not be required if performed at a participating provider or in certain states as noted.

State exceptionsThe policy lists specific jurisdictions where site‑of‑service PA requirements differ (e.g., AK, MA, PR, RI, TX, UT, VI, WI) for particular code groups.

Check code-level notesProviders should check the code‑level entries for SOS applicability because some codes are SOS‑limited while others are exempt when performed at participating providers.

SOS — outpatient hospital

Outpatient hospital SOS — PA appliesMany CPT/HCPCS codes listed require prior authorization when performed at the outpatient hospital site of service; the outpatient hospital SOS is explicitly referenced for numerous code groups.

Examples of SOS codesThe document includes outpatient hospital examples across specialties (e.g., ophthalmology, female genital system, musculoskeletal) where PA is required for the outpatient hospital POS.

Check exceptionsFor certain codes, prior authorization may not be required if performed at a participating facility or in specified states — review the SOS notes per code.

site_of_service_review

Site-of-service review as part of PASite‑of‑service review will be performed as part of the prior authorization process for many codes; exceptions by state are noted in the policy (AK, MA, PR, RI, TX, UT, VI, WI).

Applies to stimulators and othersThis SOS review requirement is applied to several device and procedure categories (stimulators, outpatient hospital procedures, etc.).

Provider actionInclude place‑of‑service details when submitting PA to ensure accurate SOS review during authorization processing.

polysomnography

Polysomnography PALaboratory‑assisted polysomnography (in‑lab sleep study) codes (e.g., 95805, 95811, 95807, 95808, 95810) require prior authorization; home sleep studies are excluded from this PA requirement.

ScopePA applies to lab‑based sleep studies used to diagnose sleep apnea and related disorders, not to home sleep testing.

Submit via PortalSubmit PA requests for polysomnography through the Provider Portal using the Prior Authorization and Notification tool.

Ventricular assist device (VAD)

Ventricular Assist Device (VAD) PAVentricular assist devices require prior authorization; providers must call the notification number on the member's ID card and fax the nurse‑provided form to the Optum VAD Case Management Team at 855‑282‑8929.

Special workflowThe policy specifies a call/fax workflow (notify via member ID card number, then fax form to Optum VAD Case Management) for VAD cases.

Device definitionVAD is defined as a mechanical pump that takes over the function of the damaged heart; PA is required per the VAD section.

Stimulators (not related to spine)

Stimulators (non‑spine) PAImplantation of stimulators not related to the spine requires prior authorization for all states; site‑of‑service review applies with state exceptions noted.

Examples of HCPCS/E‑codesDevice‑related HCPCS such as E0747, E0748, E0749, E0760 are listed in this stimulators section and are subject to PA.

State exceptionsSOS review exceptions apply for certain jurisdictions (AK, MA, PR, RI, TX, UT, VI, WI) as documented for these stimulators.

Therapeutic radiopharmaceuticals

Therapeutic radiopharmaceuticals PATherapeutic radiopharmaceuticals require prior authorization (examples include A9513, A9590); submission and predetermination instructions are provided for outpatient therapeutic radiopharmaceuticals.

Provider submission guidanceProviders should follow the specified submission/predetermination instructions in the therapeutic radiopharmaceuticals section, including Provider Portal workflows for certain nonparticipating providers.

Code examplesListed examples in this section include A9513 and A9590 among other therapeutic radiopharmaceutical HCPCS codes.