CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior Authorization Requirements for UnitedHealthcare
Lists prior authorization requirements and submission processes for UnitedHealthcare commercial plan providers (inpatient and outpatient); includes codes and special rules for select services. Affects participating providers submitting authorization requests.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements for UnitedHealthcare
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers.
No material clinical or coverage changes in this revision.
manycode lists
appliessite-of-service review
portal/phonesubmission methods
exemptemergency care
~20+drug mentions
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Genetic and molecular testing performed in an outpatient setting requires prior authorization.
Genetic and molecular testing to include BRCA gene testing (examples of CPT/HCPCS codes requiring prior authorization when performed outpatient): 81162, 81163, 81164, 81228, 81229, 81400–81405, 81448–81451, 81455–81463, 81464–81465, 81471, 81479, 81507, 81518. Prior authorization is required for other genetic/molecular tests as listed on the plan's testing/prior authorization tools.
ESRD dialysis services: Prior authorization is required when members are referred to an out-of-network dialysis provider. For notification/prior authorization call 877-842-3210. Enrollment/referral to the ESRD Disease Management Program: Kidney Resource Service at 866-561-7518.
Colonoscopy — Screening only (G0105, G0121): Site of service (SOS) review may apply; some screening colonoscopy services require SOS review or prior authorization regardless of diagnosis — submit requests via the Provider Portal or call 866-889-8054.
Surgical prior authorization
Surgical procedures and certain operative services require prior authorization; site-of-service review may apply for many codes.
Foot surgery: Prior authorization required for listed foot surgery CPT codes; site-of-service will be reviewed as part of prior authorization for specified codes (exceptions listed by state). Example CPTs: 28285, 28289, 28291–28299, 28296–28299.
Spinal/surgically implanted stimulators and implants (including cochlear, cartilage, prosthetics): Prior authorization required for implantable devices and many prosthetic codes; prior authorization required for inpatient services such as cerebral seizure monitoring. Example CPT/HCPCS: 69710, 69930, J7330, L8619, L8690, L8691 and listed prosthetic L-codes when purchase or cumulative rental > $1,000.
Gender dysphoria prior authorization
Gender dysphoria treatment requires notification or prior authorization when submitted with specified diagnosis codes.
Notification or prior authorization required for gender dysphoria treatment when submitted with diagnosis codes F64.0, F64.1, F64.2, F64.8, F64.9, or Z87.890.
Example CPTs that may require notification/prior authorization for gender dysphoria-related procedures: 55970, 55980, and a broad list of reconstructive/cosmetic procedure codes when linked to these diagnoses (examples: 14000, 14001, 14041, 15734, 15738, 15750, 15757, 15758, 19303).
Coverage notes and special conditions
Coverage notes and special conditions affecting prior authorization.
Cosmetic and reconstructive procedures: Prior authorization required for cosmetic/reconstructive procedures in all states; many specific CPTs listed under this category require prior authorization.
Site-of-service (SOS) program: Office-based procedures performed in an office typically do not require prior authorization; prior authorization is required when requesting the service in an outpatient hospital setting for many listed CPTs. SOS is reviewed as part of prior authorization for multiple codes (exceptions by state apply).
Unclassified/temporary HCPCS codes (e.g., C9172, C9399, J3490, J3590): Notification/prior authorization is required only for specified products (Beqvez, Nulibry, Rivfloza, Revcovi).
Medications: Prior authorization required for certain medications per the plan's PDL; call 800-711-4555 for drug prior authorization or fax specialty medication requests to 877-342-4596.
Potentially unproven/experimental services: Prior authorization required for services considered experimental/investigational; specific CPT examples listed (e.g., 26340, 33289, 33361–33366).
MRgFUS coverage conditions
MR-guided focused ultrasound (MRgFUS) to treat uterine fibroids requires prior authorization and is covered only under specific conditions for some plans.
Prior authorization required.
Coverage conditions (typical, plan-dependent):
- A physician and/or facility must confirm coverage of the service for the member.
- The hospital/facility must be contracted with the plan; members have no out-of-network benefits for MRgFUS.
- The member must provide written consent acknowledging limited clinical evidence on safety/effectiveness and agree not to hold the plan responsible for unsatisfactory results.
- The physician and facility must demonstrate experience and expertise in MRgFUS as determined by the plan.
Unclassified/temporary code notification rules
Unclassified and temporary codes — notification/prior authorization rules and examples.
Unclassified and temporary codes C9172, C9399, J3490, J3590: Notification/prior authorization is required only for specified high-cost or named products (Beqvez™, Nulibry™, Rivfloza™, Revcovi™).
Some unclassified/temporary codes may require prior authorization for oncology and/or non-oncology diagnoses; follow the plan's Review at Launch and prior authorization processes. For oncology DX, see cancer supportive care guidance; for non-oncology DX submit via the Provider Portal or call 888-397-8129.
Code J0885: Prior authorization is required for both oncology and non-oncology diagnoses.
Orthotics authorization criteria
Orthotics and prosthetic items may require prior authorization based on purchase or rental cost thresholds.
Prior authorization required only for orthotics/prosthetic codes with a retail purchase or cumulative rental cost greater than $1,000.
Examples of orthotics HCPCS codes that may require prior authorization when above the cost threshold: L2020, L2034, L2036, L2037, L2038, L2330, L3251, L3253, L3485, L3766, L3900, L3901, L3904, L3961, L3971, L3975.
Prior authorization and site-of-service criteria (operational notes)
Prior authorization operational notes and site-of-service review guidance.
Prior authorization is required for many listed CPT/HCPCS codes in all states; in addition, site-of-service will be reviewed as part of the prior authorization process for specified codes (exceptions include AK, MA, PR, RI, TX, UT, VI, WI).
Providers should submit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or call the applicable phone numbers listed in each service section (examples: general PA line 888-397-8129; GI/endoscopy 866-889-8054; ESRD 877-842-3210).
For inpatient admissions and post-acute services, prior authorization/notification of admission date is required for acute care hospitals, inpatient rehabilitation, critical access hospitals, LTAC, and skilled nursing facilities per plan instruction.
Some services require additional program enrollment or referral (e.g., Optum VAD Case Management for VAD; ESRD Disease Management Program contact information provided).
Screening Colonoscopy SOS and code listings
Screening colonoscopy and broader prior authorization code listings (selected examples).
Screening colonoscopy (G0105, G0121): SOS may apply; prior authorization/notification instructions available via Provider Portal or by calling 866-889-8054.
Selected example CPT/HCPCS categories and codes that commonly require prior authorization or SOS review (non-exhaustive): advanced imaging and radiology (IGRT, 77385, 77387; G6001–G6017), radiation therapy (77385, 77520–77525), therapeutic radiopharmaceuticals (A9513, A9590), prosthetic/orthotic L-codes (see orthotics block), home health and S-codes (S4015–S4037 series), and many surgical CPTs across specialties (examples in surgical blocks).
Providers should consult the plan's full CPT/HCPCS code lists and the Provider Portal for the complete, up-to-date code listings and SOS requirements.
Prior authorization requirements (medications and oncology)
Prior authorization is required for many injectable medications, oncology supportive drugs, and specialty J/Q-coded products. Examples and operational guidance follow.
Anti-emetics and cancer supportive care injectables requiring prior authorization include (examples): Akynzeo (palonosetron/fosnetupitant) J1454; Cinvanti (aprepitant) J0185; Emend (fosaprepitant) J1453/J1456; Sustol (granisetron ER) J1627.
Erythropoiesis-stimulating agents and colony-stimulating factors: Epoetin alfa J0885; filgrastim/pegfilgrastim products (J1442, Q5110, Q5125, Q5101, J2506 and biosimilar Q- or J- codes) and others listed in the supportive care sections.
Injectable chemotherapy drugs (J9000–J9999), chemotherapy Q-codes, and miscellaneous HCPCS billed oncology products generally require prior authorization. For drugs without assigned codes billed under miscellaneous HCPCS, follow prior authorization/process instructions.
Prior authorization criteria (by service category)
Prior authorization criteria organized by service category — key examples and code groupings.
Cardiac and VAD services: Prior authorization required for ventricular assist devices and related CPTs; contact the notification number on the member's ID card and follow Optum VAD Case Management instructions.
Transplant/evaluation services: Prior authorization required for transplant evaluations and pre-treatment services (example CPTs: 38240–38242, S2150; code 38232 requires PA only for oncology diagnoses).
Implantable devices and stimulators: Prior authorization required for spinal cord stimulators and related CPTs (e.g., 63685, 63688, 64553, 64570) and associated L-codes for implanted components (L86xx series).
Therapeutic radiopharmaceuticals and advanced oncology procedures: Prior authorization required for listed HCPCS (e.g., A9513, A9590) and advanced oncology interventions (see code listings).
Many specialty service categories include extensive CPT/HCPCS lists where PA and SOS review apply; consult the Provider Portal for the full, current lists.
Selected CPT and HCPCS codes that require prior authorization — consolidated (representative, not exhaustive).
Examples of CPT/HCPCS codes commonly requiring prior authorization or SOS review: 0072T (MRgFUS), 11960, 11970, 11971, 14000–14041 series, 15734–15758 series, 19303, 21243–21249, 27412–27416, 28285, 28289, 31240–31298, 33979–33983, 36340 series, 38240–38242, 49505, 49650–49651, 55700 series, 58267–58294, 62322–62361, 63662–63688, 64451, 64484, 64520, 64620, 64640, 64633–64635, 69710, 69930, G-codes and L-codes (prosthetics/orthotics) as listed. J- and Q-codes for oncology/supportive medications (see medication block).
Note: This is a representative consolidation. Providers must reference the plan's full published PA code lists and the Provider Portal for the definitive, current code lists and any state-specific exceptions.
CPT / HCPCS / ICD-10 Code Listings
Arthroplasty CPT/HCPCS examplesCPT
23470
Arthroplasty-related CPT/HCPCS code listed for prior authorization
23472
Arthroplasty-related CPT/HCPCS code listed for prior authorization
23473
Arthroplasty-related CPT/HCPCS code listed for prior authorization
23474
Arthroplasty-related CPT/HCPCS code listed for prior authorization
Bone marrow harvest / transplant related CPT (example listed under transplant services)
Radiopharmaceuticals and cellular/gene therapy codesmixedCovered
A9513
Therapeutic radiopharmaceutical
0537T
Cellular/gene therapy procedure code
Ventricular assist CPT codesCPT
33927
Ventricular assist device — referenced in document
33928
Ventricular assist device — referenced in document
33929
Ventricular assist device — referenced in document
33975
Ventricular assist device — referenced in document
33976
Ventricular assist device — referenced in document
33979
Ventricular assist device — referenced in document
33981
Ventricular assist device — referenced in document
33982
Ventricular assist device — referenced in document
33983
Ventricular assist device — referenced in document
Cardiac procedure codes referencedCPT
33983
Listed in document as CPT/HCPCS code requiring prior authorization
33979
Listed in document as CPT/HCPCS code requiring prior authorization
33981
Listed in document as CPT/HCPCS code requiring prior authorization
33982
Listed in document as CPT/HCPCS code requiring prior authorization
Listed procedure codesCPT | HCPCS
33979
33981
33982
33983
inv-49: Age threshold for certain cardiovascular prior authorizations
Age thresholdPrior authorization required for certain cardiovascular procedures for patients aged 18 years and older; separate guidance applies for patients under 18 (see congenital heart disease section).
How Providers Obtain Prior Authorization / Actions Required
Prior Authorization
How to submit prior authorization requests
Prior authorization (PA) is required for many medications and procedures listed below. Submit requests online using the Prior Authorization and Notification tool on the Provider Portal (UHCprovider.com → Sign In → Prior Authorization and Notification) or call the numbers shown for specific services. Emergency and urgent care are excluded from PA.
General: PA not required for emergency/urgent care
Portal: UHCprovider.com > Sign In > Prior Authorization and Notification
Phone: 866-889-8054 (general PA)
Prior Authorization
Cancer supportive care: injectable and bone-modifying agents
Certain outpatient injectable and bone-modifying agents used for cancer supportive care require prior authorization. This includes colony-stimulating factors, erythropoiesis-stimulating agents and denosumab when used for oncology indications. Some HCPCS/Q codes listed below also require PA when used for non-oncology diagnoses — check the Injectable medications section for details.
Definitions and Terms
inv-107: Prior authorization
Definition: Prior authorizationA pre-service review requirement where providers must obtain approval before delivering certain services; prior authorization is not required for emergency or urgent care.
How to submitSubmit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or connect via 24/7 chat; phone alternatives are provided in service-specific sections.
Portal requirementUsing the Provider Portal requires a One Healthcare ID to sign in and access the Prior Authorization and Notification tab.
inv-108: Cancer supportive care prior authorization
Scope: cancer supportive carePrior authorization required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis.
Cross-application
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior Authorization Requirements for UnitedHealthcare
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the listed phone numbers.
Transplant services: Prior authorization required for transplant or transplant-related services prior to pre-treatment or evaluation (example CPTs: 38240–38242; see transplant section for full process).
- A physician and facility must follow applicable U.S. FDA requirements and any plan-specific protocols.
For prior authorization of injectable and specialty medications use the Prior Authorization and Notification tool on the Provider Portal or call the plan's pharmacy prior authorization numbers as listed; specialty medication fax number: 877-342-4596. See the PDL/Drug Lists for the full medication PA list and details.
inv-50: Chemotherapy drugs billing under miscellaneous codes
Chemotherapy billing scopePrior authorization required for chemotherapy injectables in range J9000–J9999 and for agents with Q-codes.
Miscellaneous HCPCSPrior authorization required for chemotherapy agents billed under miscellaneous/unassigned HCPCS codes (agents without an assigned code).
Specific non-chemotherapy drugs listedLeucovorin (J0640), levoleucovorin (J0641, J0642) and selected hormonal/antineoplastic agents listed require prior authorization when applicable.
inv-51: DME cumulative rental/purchase threshold
DME cost thresholdNotification/prior authorization required when cumulative rental or retail purchase cost for listed DME items exceeds $1,000.
Examples of affected DME codesExamples include E0300, E0329 and other E-series HCPCS codes listed in the DME section—check code list for specifics.
Submission noteOnly the DME codes listed in the policy require notification/prior authorization; other DME items are not subject to this threshold note.
inv-52: Prior authorization conditional on diagnosis
Diagnosis-conditional PACertain S-codes and listed CPT codes require prior authorization only when submitted with specific diagnosis codes that meet the policy criteria.
Examples notedThe policy indicates examples where authorization applies only if DX code matches listed conditions (see code lists S4031, S4035, S4037 and related notes).
Provider actionWhen filing PA for conditional codes, include the applicable diagnosis code to determine whether PA is required.
Prosthetic thresholdPrior authorization required for prosthetic codes only when retail purchase or cumulative rental cost exceeds $1,000.
Representative prosthetic L-codesExamples include L5010, L5050, L5060, L5100 and numerous other L‑codes enumerated in the prosthetics section.
Distinction from DMEPolicy notes that prosthetics are not DME for purposes of some rules; apply prosthetic-specific threshold language as listed.
inv-55: 38232 oncology requirement
38232 oncology-only PACode 38232 requires prior authorization only when billed with an oncology diagnosis.
ContextThis oncology-only requirement is stated alongside transplant/cellular therapy codes; verify DX when submitting PA for 38232.
Colony-stimulating factors and bone-modifying agents administered outpatient for cancer require PA
Codes with special PA rules: J0897, J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125
For non-oncology DX of certain codes, see Injectable medications section
Prior Authorization
Arthroscopy: site-of-service review and prior authorization
Site-of-service review and prior authorization are required for the arthroscopy and other listed procedural codes in outpatient hospital settings (exceptions by state noted in the policy). Verify place-of-service and obtain PA when requesting these procedures in an outpatient hospital vs an ambulatory surgery center or office.
Site-of-service (SOS) review applies to listed arthroscopy codes (see policy)
Exceptions: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin
Obtain PA if requesting outpatient hospital setting for SOS-reviewed codes
Prior Authorization
Medications requiring prior authorization
Many injectable medications require prior authorization. This includes anti-emetics, colony-stimulating factors, erythropoiesis-stimulating agents and chemotherapy injectables. Follow specialty pharmacy/portal submission workflows where indicated and refer to the Review at Launch and PDL resources for newly approved drugs.
Chemotherapy injectables: J9000–J9999, leucovorin J0640, levoleucovorin J0641/J0642 and specified hormonal/antineoplastic injectables require PA
Unclassified/temporary codes: C9172, C9399, J3490, J3590 — notification/PA only for specified products (Beqvez™, Nulibry™, Rivfloza™, Revcovi™)
Prior Authorization
How to obtain prior authorization
Submit PA requests online via the Prior Authorization and Notification tool on the Provider Portal (UHCprovider.com) or call the vendor numbers below when specified. For specialty drug questions use the Specialty Pharmacy Transactions tile on the Provider Portal; for injectable/oncology drugs call Optum at 888-397-8129 for assistance when noted.
Online: UHCprovider.com → Sign In → Prior Authorization and Notification
Many outpatient procedures and device implantations require prior authorization. Review the policy code lists for specialty areas (radiology, surgery, ENT, orthopedics, prosthetics, transplant, VAD/Ventricular Assist, stimulators, radiation therapy and others) and obtain PA before scheduling outpatient hospital or ASC services when required.
Radiology advanced outpatient imaging (certain CT/MRI/MRA/PET/nuclear studies) — PA required
Spinal cord and other neurostimulators — PA required (see stimulator codes)
Ventricular assist devices (VAD) and related surgical codes — PA and notification required
Transplant evaluations and transplant-related services — PA required prior to pre-treatment/evaluation
Note
Age-based prior authorization note
Age-based prior authorization rules apply for selected services — for example, certain cardiology procedures require PA only for patients 18 and older, and different rules may apply for congenital heart disease in pediatric patients. Always check the age-specific notes in the code lists and clinical sections.
Some PA requirements apply only for patients ages 18 and older
See congenital heart disease section for pediatric (under 18) rules
Code-level notes may specify age-based exceptions
Prior Authorization
ESRD out-of-network prior authorization
When members require dialysis from an out-of-network provider, prior authorization is required. For notification or PA for ESRD dialysis services and to enroll or refer members to ESRD Disease Management, use the contacts below.
Out-of-network dialysis: prior authorization required when referred to out-of-network dialysis provider
Notification/PA phone for ESRD dialysis services: 877-842-3210
Surgical procedures prior authorization and site-of-service review
Surgical procedures may be subject to both prior authorization and site-of-service (SOS) review. When an SOS review applies, PA will consider the requested place of service (office preferred when clinically appropriate). Confirm whether PA is required for the code and whether SOS review applies before scheduling.
Site-of-service review may require procedures to be moved from outpatient hospital to ASC or office when clinically appropriate
Prior authorization required for many inpatient and outpatient surgical codes listed in the policy
If PA is required only for outpatient hospital setting, performing the service in a participating ASC or office may avoid PA — verify contract status
Note
Colonoscopy screening SOS note
For colonoscopy screening-only codes G0105 and G0121, site-of-service rules may apply. Submit PA or advance notification as directed through the Provider Portal or by calling the PA line. See Gastroenterology Endoscopy Advance Notification for full CPT lists and SOS guidance.
Screening colonoscopy codes: G0105, G0121 (SOS may apply)
Submit PA via Provider Portal or call 866-889-8054
Refer to Gastroenterology Endoscopy Advance Notification for expanded code lists
Prior Authorization
Gender dysphoria treatment prior authorization
Gender dysphoria treatments and related surgical procedures require notification or prior authorization when submitted with gender dysphoria diagnosis codes (F64.x or Z87.890). Specific CPT codes for procedures commonly associated with gender-affirming surgery are listed in the policy and require PA/notification.
Notification/PA required when procedure is submitted with diagnosis codes F64.0–F64.9 or Z87.890
Example CPTs listed: 55970, 55980 and many reconstructive/cosmetic CPTs (14000 series, 15734, 15738, 15750, 15757–15758, 19303, 193xx series)
Follow policy for documentation requirements and submission route
The policy includes a large (partial) list of CPT/HCPCS codes that require prior authorization — this list is not exhaustive. Providers must review the code lists in the policy for their specialty and submit PA where a code appears. When codes are identified as SOS-reviewed, PA may include a place-of-service determination.
Code lists across specialties (cardiology, orthopedics, ENT, GI, radiology, pain management, stimulators, etc.) require PA
Some codes have conditional rules (only require PA with certain diagnosis codes) — check the policy
SOS-reviewed codes may trigger site-of-service review in addition to PA
Prior Authorization
Injectable medications prior authorization process (partial)
Partial process for injectable medication PA: use the Provider Portal Specialty Pharmacy tile or the Prior Authorization tool; for many oncology/injectable drugs Optum manages PA and can be contacted at 888-397-8129. For unclassified or miscellaneous HCPCS billed products (J3490/J3590/C9172/C9399), PA/notification applies only for specified products — confirm product-specific rules.
Portal submission recommended for specialty injectables and oncology drugs
Optum phone for injectable/oncology PA: 888-397-8129
Unclassified/temporary codes: PA/notification required only for select products (see policy footnotes)
Note
Conditional prior authorization by diagnosis
Some prior authorizations are conditional based on diagnosis — e.g., code 38232 requires PA only for oncology diagnoses; other codes may require PA only when billed with specific DX ranges. Check code-level notes in the policy for conditional PA by diagnosis.
Code 38232: PA only when billed for an oncology diagnosis
Many codes list conditional PA when submitted with specific diagnosis ranges — review the policy code notes
If a code is listed as ‘PA required only if DX is…’ confirm the DX on the claim prior to submission
For unclassified and temporary HCPCS codes (C9172, C9399, J3490, J3590) the policy requires notification/PA only for named products recently launched or with special review status (see Review at Launch list). Providers should check the Review at Launch medication list and submit predetermination when indicated.
Unclassified/temporary codes: C9172, C9399, J3490, J3590 — notification/PA only for Beqvez™, Nulibry™, Rivfloza™, Revcovi™
Check the Review at Launch medication list for newly approved drugs that require predetermination
Predetermination recommended for drugs on Review at Launch
Prior Authorization
Non-emergency air transport
Non-emergency air transport requires prior authorization. Use the listed ambulance air transport HCPCS codes when requesting PA and follow the PA submission process for transportation services.
Non-emergency air transport HCPCS: A0430, A0431, A0435, A0436
Prior authorization is required for nonurgent ambulance transportation by air
Submit PA via Provider Portal or as directed in transportation policy notes
Prior Authorization
Prostate procedures and prosthetics prior auth threshold
Prostate procedures generally require prior authorization. Prosthetic/prosthesis codes require PA only when retail purchase or cumulative rental cost exceeds $1,000. Verify prosthetic thresholds before delivery and submit PA when the cost threshold is met.
Prostate procedural CPTs require PA (examples listed in policy: 52441, 52442, 53850, 55874)
Prosthetic codes (L-series) require PA only if retail purchase or cumulative rental cost > $1,000 (examples: L5010, L5050, L5060, etc.)
Confirm cost threshold and submit PA when applicable
Selected submission instructions and operational notes: include clinical documentation supporting medical necessity, indicate the requested place of service (SOS), include diagnosis codes that trigger or exempt PA, and for transplant/VAD/stimulator services follow the special contact/fax workflows listed in the policy.
Include supporting clinical documentation and relevant DX when submitting PA
If SOS is relevant, document why outpatient hospital (versus ASC/office) is clinically necessary
Transplant: obtain PA prior to pre-treatment/evaluation and use the transplant contacts; Cellular and gene therapies often require prior authorization and special routing
VAD: call the notification number on the member's ID card and fax required forms to Optum VAD Case Management at 855-282-8929
Prior Authorization
Spinal cord and other stimulator devices
Spinal cord stimulators, neurostimulators and related device implantations require prior authorization. Many CPT and HCPCS codes for stimulator placement, trials and neurostimulator systems are listed and PA is required across states (SOS review may also apply).
Spinal cord stimulator procedural CPTs: 63685, 63688 and related implantation codes require PA
Neurostimulator device HCPCS/L-codes (L8679, L8680, L8682–L8688, L8685–L8687 etc.) require PA
PA required for stimulator trials, permanent implantation and non-spine stimulators per code list
Prior Authorization
Neurostimulator / implantation codes
Neurostimulator implantation and related codes require prior authorization. PA applies to implantation, programming, and replacement codes; check the detailed code listings and follow the portal or vendor-specific submission path.
Neurostimulator CPTs/HCPCS requiring PA include 61863–61868, 61885–61886, 64555, 64568, 64590*, 64595 and related codes
Some combinations or diagnosis-specific scenarios may be exempt — review policy notes (e.g., certain incontinence code combinations)
Submit PA via Provider Portal or the phone numbers provided for device/service-type
Prior Authorization
Transplant / cellular and gene therapy
Transplant services (organ/tissue transplant evaluation, pre-treatment and transplant-related services) require prior authorization before evaluations and pre-treatment. Cellular and gene therapies (CAR-T, gene-modified cell therapies, etc.) require PA and often special routing — contact the transplant/cellular therapy desk listed in the policy.
PA required for transplant evaluations and transplant-related services (examples: 38240–38242 for hematopoietic procedures, multiple organ-specific CPTs listed)
Cellular and gene therapies (Abecma®, Breyanzi®, Carvykti™, Tecartus™, Yescarta™, Kymriah™, Lantidra™, others) require PA and special handling
For CAR-T and newer agents, call 888-936-7246 or the notification number on the member's ID card as instructed
Prior Authorization
Prior authorization codes for ventricular assist
Ventricular assist device (VAD) implantation and related services require prior authorization and notification. Call the notification number on the member ID card and follow the Optum VAD Case Management workflow; fax the required form to 855-282-8929 as instructed in the policy.
VAD-related CPTs include 33927, 33928, 33929, 33975, 33979, 33981–33983 (and others listed) — PA required
Call the notification number on the member's ID card for initial contact
Fax required forms to Optum VAD Case Management at 855-282-8929
The policy contains many fragmented lists of procedure codes that require prior authorization across specialties. Providers must consult the full policy code lists for their procedure and follow the submission instructions (portal or phone) shown for each item.
Many procedure codes include SOS notes, cost thresholds, or DX-dependent PA rules — confirm details in the policy
When in doubt, submit a predetermination via the Provider Portal to avoid claim denials
Prior Authorization
CPT/HCPCS codes and how to obtain prior authorization
CPT and HCPCS code-level guidance and how to obtain prior authorization: use the Provider Portal Prior Authorization and Notification tool for most outpatient and injectable requests; call specialty vendor numbers for radiology, transplant, VAD, ESRD, Optum Physical Health, or other services as indicated in code sections. Include all requested supporting documentation to expedite review.
Primary submission method: Provider Portal → Prior Authorization and Notification
Radiology PA: 866-889-8054 or portal per Radiology Prior Authorization guidance
Optum Physical Health (PT/OT) and other specialty contacts as listed in policy
Certain listed J-/Q-codes (e.g., J0897, J1442, J1447, J2506, Q5101, Q5110, Q5125) also require PA when used for non-oncology diagnoses per policy notes.
Submission pathSubmit PA for these agents via the UnitedHealthcare Provider Portal or as directed in the injectable medications section (contact numbers provided for specialty cases).
inv-109: Prior authorization
Provider submission methodsPrior authorization requests may be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (service-specific contact numbers listed elsewhere).
Emergency carePrior authorization is not required for emergency or urgent care services.
Portal access noteAccess to the Provider Portal requires signing in with a One Healthcare ID; instructions are provided for obtaining access.
inv-110: Clinical trials
Clinical trials (note)Clinical trials are referenced as rigorously controlled studies; some trial-related codes (S9988, S9990, S9991) and trial services may require prior authorization per section notes.
Trial codes exampleThe policy lists clinical-trial related codes in context but directs providers to apply PA rules as indicated for those services.
inv-111: ESRD dialysis services
ESRD dialysis services definitionServices for treating end-stage renal disease, including outpatient dialysis services; prior authorization required when members are referred to an out‑of‑network dialysis care provider.
Contact linesNotification/prior authorization for ESRD dialysis: call 877-842-3210; ESRD Disease Management Program enrollment: 866-561-7518.
inv-112: Durable medical equipment (DME)
DME definition and thresholdDurable medical equipment (DME) items listed may require notification/prior authorization when billed as a retail purchase or when cumulative rental exceeds $1,000.
Examples of DME HCPCSExamples provided include E0300, E0329, E0466 and multiple E-series HCPCS codes listed in the DME section.
inv-113: Site of Service (SOS)
Site of Service (SOS) conceptSite of service indicates that prior authorization applicability or review may depend on where the procedure is performed (office versus outpatient hospital); office-based program may be exempt from PA in some cases.
Office-based exemptionUnder the SOS office-based program, prior authorization is not required if the procedure is performed in an office; PA is required when performed in an outpatient hospital setting.
Ordering provider responsibilityFor advanced outpatient imaging and other SOS‑sensitive services, the ordering provider is responsible for requesting prior authorization before scheduling.
inv-114: Advance Notification
Advance NotificationAdvance notification is encouraged for certain procedures (for example, gastroenterology endoscopy), though formal prior authorization may still be required for specific codes.
Where to find detailsSee the Gastroenterology Endoscopy Advance Notification resources and code lists for procedure-specific instructions.
inv-115: Injectable medications
Injectable medications definitionA drug capable of being injected intravenously via infusion, subcutaneously or intramuscularly; many injectable HCPCS/J‑codes listed require prior authorization.
Submission pathwayProviders must use the UnitedHealthcare Provider Portal (Specialty Pharmacy Transactions tile) or designated phone numbers for injectable medication prior authorization/predetermination.
inv-116: Home health care prior authorization note
Home health care PA notePrior authorization required only in outpatient settings for specified home health care services; some home-based services are excluded.
ExamplesLists include S3854, S3865, S3870 and various T‑ and S‑codes for home health care items where outpatient PA applies.
inv-117: MR-guided focused ultrasound
MRgFUS definition and PAMR-guided focused ultrasound (MRgFUS) to treat uterine fibroid requires prior authorization; coverage limited to certain benefit plans with member written consent and facility/provider requirements.
Code exampleMRgFUS CPT code referenced: 0072T.
inv-118: Review at Launch
Review at Launch referencePolicy references the 'Review at Launch' process for newly approved medications and recommends predetermination for drugs on that list.
Unclassified/temporary code handlingNotification/PA for C9172, C9399, J3490, J3590 is required only for named drugs (Beqvez™, Nulibry™, Rivfloza™, Revcovi™); check Review at Launch for updates.
inv-119: Site of Service (SOS) note
SOS office-based programSite of service (SOS) office-based program: PA not required if the service is performed in an office; PA required when performed in an outpatient hospital setting.
Examples of applicable codesThe policy lists numerous CPT/HCPCS codes where SOS rules apply—see section for specific codes and exceptions.
Potentially unproven / experimental servicesServices lacking sufficient high‑quality published evidence are considered potentially unproven/experimental and require prior authorization and review.
ExamplesExamples include CPT codes 26340, 33289, 33361–33366 and others listed in the potentially unproven services section.
inv-121: Site of service (SOS) - office-based program
SOS office-based program (office preferred)The office is the preferred place of service for many procedures; SOS rules may exempt office-based services from PA while requiring PA in outpatient hospital settings.
Radiology SOS noteAdvanced outpatient imaging (CT, MRI, MRA, PET, nuclear medicine) requires PA and ordering providers must request PA before scheduling.
inv-122: Advanced outpatient imaging
Advanced outpatient imagingCertain CT, MRI, MRA, PET and nuclear medicine/nuclear cardiology procedures require prior authorization; ordering providers are responsible for requesting PA prior to scheduling.
How to submitSubmit PA online via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 866-889-8054 for assistance.
inv-123: Site of service (SOS) - facility setting
SOS facility setting definitionSite of service (SOS) - outpatient hospital denotes facility settings where PA requirements may differ from office-based services.
PA applicabilityMany CPT/HCPCS codes listed in the SOS outpatient hospital section require prior authorization when performed in that setting.
inv-124: Site-of-service (SOS)
Site-of-service termSite-of-service (SOS) indicates the place where a procedure is performed and can change PA applicability (office vs outpatient hospital vs ASC).
Office vs hospitalUnder SOS rules, procedures performed in-office may be exempt from PA that applies when the same procedure is performed in an outpatient hospital.
inv-125: Sleep studies
Sleep studies requiring PALaboratory-assisted sleep studies (polysomnography) and related studies that diagnose sleep apnea require prior authorization; excludes home sleep studies.
Example CPT codesExamples listed include 95805, 95807, 95808, 95810 and related sleep study codes.
inv-126: Ventricular assist devices (VAD)
VAD definition and PAVentricular assist devices (VAD) are mechanical pumps that take over function of the damaged ventricle and restore normal blood flow; prior authorization is required.
How to obtain PACall the notification number on the member's ID card, then fax the required form to the Optum VAD Case Management Team at 855-282-8929.
Example VAD codesDocument references CPT codes such as 33927, 33928, 33929, 33975, 33979, 33981–33983 for VAD procedures requiring PA.
Ventricular assist device termA mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.
Related codesMultiple CPT codes are listed in the VAD section (examples: 33927, 33928, 33929, 33975, 33979, 33981–33983); PA required for these services.
inv-128: ventricle of the heart
Ventricle of the heart referenceThe policy text repeatedly references 'ventricle of the heart' in descriptions of ventricular assist procedures and associated CPT codes.
Clinical contextReferences appear alongside the VAD code listings and instructions for prior authorization and case management routing.
inv-129: restores normal blood flow / ventricle of the heart
Restores normal blood flow phraseThe document repeatedly states that VADs 'restore normal blood flow' in descriptions of ventricular assist procedures and associated codes.
Operational noteProviders must follow the specified notification and fax process (notification number on member ID then fax to Optum VAD Case Management) to obtain PA for these services.