CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for Virginia Cardinal Care

Lists services, CPT/HCPCS/diagnosis codes, and submission methods for prior authorization required for participating UnitedHealthcare Community Plan of Virginia / Virginia Cardinal Care providers. Applies to inpatient and outpatient services and participating providers; emergency/urgent care is excluded.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 844-284-0146.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipleservice categories listed

Online/Phonesubmission methods

Yesemergency care exempt

20+drug codes listed

Requiredinjectable chemotherapy

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.

ExistsOptum Transplant pathway

Prior Authorization Coverage Criteria

High-level prior authorization requirements

Specific services and codes require prior authorization as listed; emergency or urgent care is excluded.

Prior authorization is required for the services and codes enumerated in this document.

Emergency or urgent care services do NOT require prior authorization.

Providers should follow the submission instructions (provider portal or phone) listed in the document when requesting prior authorization.

Listed prior authorization requirements

Services and codes requiring prior authorization as listed below.

Injectable chemotherapy administered in outpatient settings (intravenous, intravesical, intrathecal) for a cancer diagnosis requires prior authorization.

Cochlear implants and other auditory implants require prior authorization.

Continuous glucose monitor HCPCS codes require prior authorization when billed with a type 2 diabetes diagnosis.

Inpatient video EEG monitoring requires prior authorization for inpatient services (specific CPT codes listed); outpatient/ambulatory EEG does not require prior authorization.

Prior authorization required items

Items and services listed below require prior authorization.

Durable medical equipment (DME) codes listed in the document require prior authorization.

Many procedure, CPT and HCPCS codes enumerated (including selected injectable chemotherapy codes and others shown) require prior authorization as listed.

Experimental and investigational items and linked services listed in the document require prior authorization.

Prior authorization coverage criteria (partial)

Services and codes listed below require prior authorization as stated in their Additional Information notes.

Injectable medications listed (sample codes and examples provided) require prior authorization; providers should submit requests via the UnitedHealthcare Provider Portal or the contact number shown.

Genetic and molecular testing CPT/HCPCS codes listed (examples: 81162, 81229, 81403, 81407, 0037U, etc.) require prior authorization.

Home health care requires prior authorization only in outpatient settings (including member's home).

Hysterectomy and selected surgical codes listed require prior authorization as shown in the Additional Information section.

Gender dysphoria–related surgical codes and associated diagnosis codes require prior authorization per the document notes.

Prior authorization coverage criteria (partial listings from this document)

Prior authorization is required for the injectable medications and certain HCPCS/CPT codes listed below. Submission instructions and special notes are included for subsets of codes and products.

Specific injectable medications (many J- and Q-codes listed in the document) require prior authorization; some products require Optum Rx prior notification as noted.

White blood cell colony-stimulating factor codes (examples: J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non-oncology diagnoses; oncology supportive-care requests reference the Cancer supportive care section.

Total hip and knee replacement CPT codes enumerated in the joint replacement section require prior authorization.

Occupational and physical therapy CPT codes listed require prior authorization after the initial evaluation and before initiating therapy.

Non-emergent air ambulance transport codes listed require prior authorization.

Prior authorization requirements (excerpt)

Selected services and codes require prior authorization as indicated below.

Orthognathic and maxillofacial procedure CPT codes listed (e.g., 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, etc.) require prior authorization.

Orthotics and prosthetics L-codes require prior authorization when retail purchase, cumulative purchases, or rental costs exceed specified thresholds (numerous L-codes listed).

Private duty nursing (T1000, T1002, T1003) and potentially unproven services listed (examples: 33289, C2624) require prior authorization.

Radiation fractionation prior authorization

Prior authorization is required for certain radiation therapy fractionation requests and is only required to manage fractionation when requested for applicable diagnoses.

Prior authorization is required to manage fractionation for radiation treatment delivery codes (e.g., 77402, 77407, 77412, 79445, S2095) when requested for specified ICD-10 cancer diagnoses (examples: bone metastases, breast cancer, prostate cancer).

Applicable diagnosis examples

Bone metastases (ICD-10 examples: C79.51, C79.52)
Breast cancer (multiple C50.* and D05.* codes listed in the document)
Prostate cancer (ICD-10: C61)

Submit radiation therapy prior authorization requests via the UnitedHealthcare Provider Portal or by calling the phone numbers provided in the radiation/radiology sections.

Transplant and CAR T prior authorization

Transplants and CAR T-cell therapies require prior authorization.

Prior authorization is required for transplant services and CAR T-cell therapies (listed agents include Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta).

For CAR T/gene therapy and certain unclassified-code products follow the specified authorization pathways noted in the document (e.g., Optum Transplant routing for unclassified codes where applicable).

Surgical and supportive services prior authorization

Various surgical, imaging, and supportive services require prior authorization.

Rhinoplasty and septoplasty for treatment of nasal functional impairment require prior authorization (CPT codes listed, e.g., 30400–30450 series).

Sinuplasty requires prior authorization (CPT codes 31295–31298 listed).

Speech therapy requires prior authorization after the initial evaluation and before the initial therapy visit, and for ongoing therapy visits (CPT codes such as 92507, 92508, 92526 listed).

Private duty nursing, prostate procedures, and other listed surgical/supportive services require prior authorization as enumerated in the document.

Submission instructions

How to submit prior authorization requests.

Submit prior authorization requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call the phone numbers provided in the document (examples: 866-889-8054; 888-397-8129).

Health care professionals ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; follow the Radiology Prior resources referenced in the document for details and CPT code lists.

Authorization requirements for selected categories

Explicit coverage/action stance for certain device and procedure categories:

Prior authorization required: Vein procedures (removal and ablation of saphenous veins), ventricular assist devices (VAD) implantation, and wound VAC (E2402) require prior authorization; follow the notification/fax instructions for VADs (fax to Optum VAD Case Management at 855-282-8929) as specified.

VAD notification: For VADs, call the notification number on the member's ID card and fax the form provided by the nurse to Optum VAD Case Management at 855-282-8929.

Special code handling

Special authorization pathways for certain codes:

Optum Transplant routing: Unclassified drug codes J3490, J3590, and C9399 require prior authorization through Optum Transplant (Amtagvi) as noted in the document.

Oncology-only condition: CPT 38232 requires prior authorization only when submitted with an oncology diagnosis (per document note).

Relevant CPT / HCPCS / ICD-10 Codes

Injectable oncology and bone agentsHCPCSCovered

Q5101	Zarxio (biosimilar) - colony-stimulating factor
J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5122	Pegfilgrastim-apgf (Nyvepria)
J2506	Pegfilgrastim (Neulasta)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (Udenyca)
J2820	Sargramostim (Leukine)

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Breast reconstruction CPT codes (sample)CPTCovered

19316	Breast reconstruction CPT examples listed
19330	Breast reconstruction CPT examples listed
19357	Breast reconstruction CPT examples listed

Injectable chemotherapy HCPCS/J-codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (additional)
J1950	Lupron Depot
J1954	Leuprolide acetate
J1932	Lanreotide

Inpatient video EEG CPT codesCPTCovered

95700	EEG monitoring service code
95711	EEG monitoring

Continuous glucose monitor HCPCS codesHCPCSCovered

A4226	Continuous glucose monitor supply
A9278	CGM related code

sample chemotherapy and procedure codesmixed

Q2026	HCPCS code listed repeatedly in injectable chemotherapy section
67915-67966	Range of CPT codes referenced in chunk 36 (surgical/ophthalmologic codes appear listed)

diagnosis codes tied to prior authICD-10

C43.* / C44.* / C46.*	Multiple ICD-10 codes for malignant neoplasms of skin referenced as related diagnoses
D03., D04.	ICD-10 codes for melanoma in situ / carcinoma in situ referenced

Sample injectable medication J/Q codes (partial list)HCPCSCovered

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J7171	Adzynma
J1552	Alyglo
J1426	Amondys 45
J0225	Amvuttra
Q5121	Avsola
Q5156	Avtozma
J1072	Azmiro

Genetic and molecular testing CPT/HCPCS codes (partial)mixedCovered

81162	Genetic testing code (example)
81229	Genetic testing code (example)
81403	Molecular pathology procedure
81407	Targeted sequencing panel
0037U	Clinical laboratory code (U-code example)

Surgical CPT codes linked to gender dysphoria and related services (partial)CPTCovered

14000	Gender dysphoria related CPT code (example)
15757	Gender dysphoria related CPT code (example)
17380	Skin lesion excision (listed in section)

Selected injectable medication HCPCS codesHCPCSCovered

J2327	Skyrizi
J1745	Remicade
J3399	Zolgensma
J1442	White blood cell colony-stimulating factor (example)

Selected joint replacement CPT codesCPTCovered

27130	Total hip arthroplasty
27447	Revision of knee arthroplasty

Selected therapy CPT codesCPTCovered

97110	Therapeutic exercises
97530	Therapeutic activities

Maxillofacial/orthognathic CPT codesCPTCovered

21121	Orthognathic surgery codes listed
21123	Orthognathic surgery codes listed
21125	Orthognathic surgery codes listed

Orthotics/prosthetics L-codesHCPCSCovered

L0112	Orthotic/prosthetic HCPCS L-code example
L5716	Orthotic/prosthetic HCPCS L-code example

Miscellaneous CPT/HCPCS codesmixedCovered

T1000	Private duty nursing
33289	Potentially unproven service example

Radiation therapy codesCPTCovered

77387	Image-guided radiation therapy (IGRT)
77520	Proton beam - technical code
77522	Proton beam - technical code
77523	Proton beam - technical code
77525	Proton beam - technical code
77331	Special/associated services
77370	Special/associated services
77399	Special/associated services
77470	Special/associated services
77371	SRS/SBRT

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Spinal and neurosurgical procedure codes (examples)CPTCovered

22100	Spinal surgery
22101	Spinal surgery
22551	Spinal surgery
22855	Spinal instrumentation
63001	Spinal procedures
63286	Spinal procedures
0098T	Specific procedure/temporary code referenced

Potentially unproven servicesmixedNot Covered

33289	Potentially unproven services (listed)
C2624	Potentially unproven services (HCPCS)

CAR T-cell therapiesNDCCovered

Abecma	idecabtagene cileucel, CAR T therapy - prior authorization required
Breyanzi	lisocabtagene maraleucel, CAR T therapy - prior authorization required
Carvykti	ciltacabtagene autoleucel, CAR T therapy - prior authorization required
Kymriah	tisagenlecleucel, CAR T therapy - prior authorization required
Tecartus	brexucabtagene autoleucel, CAR T therapy - prior authorization required
Yescarta	axicabtagene, CAR T therapy - prior authorization required

Listed surgical/procedure CPT codesCPT

38209
38210
38212
38213
38214
38215
38232	prior authorization only for oncology diagnosis (note in document)
38240
38241
38242

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HCPCS/J-code/Q-code entriesHCPCS

S2060
S2061
S2152
J3389
J3391
J3392
Q2041
Q2042

What Providers Must Do

Prior Authorization

How to obtain prior authorization (general portal/contact)

Submit prior authorization requests online using the UnitedHealthcare Provider Portal Prior Authorization and Notification tool. To get started, go to UHCprovider.com and click Sign In (top-right) to log in with your One Healthcare ID and password. If you do not have a One Healthcare ID, visit UHCprovider.com/access to create one. After signing in, select the Prior Authorization and Notification tab on your dashboard to submit requests.

Online: UHCprovider.com — Prior Authorization and Notification tab (One Healthcare ID required)
Phone support for many injectable medications and services: 888-397-8129
Alternate phone numbers shown for select services: 844-284-0146, 866-889-8054 (radiation/radiology)

Prior Authorization

Wound vac — Prior authorization required

Prior authorization is required for negative-pressure wound therapy (wound VAC) when billed with code E2402. Providers must obtain authorization prior to initiating wound VAC services.

Wound vac HCPCS: E2402 — prior authorization required

Key Definitions and Scope Notes

Prior authorization — Prior authorization submission methods

Submission methodsOnline via UnitedHealthcare Provider Portal Prior Authorization and Notification tool (One Healthcare ID) or by phone at 844-284-0146.

Portal accessGo to UHCprovider.com, Sign In with One Healthcare ID, then select Prior Authorization and Notification tab.

Phone submissionCall 844-284-0146 to submit prior authorization requests.

Out-of-network requirementOut-of-network physicians, facilities and other providers must request prior authorization for all procedures and services.

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

Emergency or urgent care — Services provided for emergency or urgent care do not require prior authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Virginia Cardinal Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool or by phone at 844-284-0146.

SourceLink

On This Page

Orthognathic and maxillofacial CPT codes listed require prior authorization.

Obtain authorization through the UnitedHealthcare Provider Portal (UHCprovider.com) or by calling the applicable prior authorization phone number shown on the member's plan communications

General ruleServices provided for emergency or urgent care do not require prior authorization.

Inpatient video EEG noteInpatient video EEG monitoring requires prior authorization for inpatient services but not for outpatient hospital or ambulatory surgical center.

Provider action for non-emergent servicesFor non-emergent inpatient/ambulatory services, obtain prior authorization via the portal or phone as specified.

Injectable chemotherapy — Injectable chemotherapy drugs

ScopePrior authorization required for injectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis.

Code range examplesChemotherapy injectable drugs range J9000-J9999; specific examples listed include J0640, J0641, J0642, J1950, J1954, J1932.

Submission noteFollow portal/phone submission instructions; oncology supportive-care requests reference the Cancer supportive care section.

Cochlear implant — Cochlear implant: a medical device within the inner ear and an external portion that helps persons with profound sensorineural deafness a...

DefinitionCochlear implant: a medical device within the inner ear and an external portion that helps persons with profound sensorineural deafness achieve conversational hearing.

Authorization requirementPrior authorization is required for cochlear implants and other auditory implants.

CodesCPT/HCPCS codes for cochlear and auditory implants are listed in the document where applicable.

Inpatient video EEG — Inpatient video electroencephalogram (EEG): extended EEG monitoring performed in an inpatient setting; prior authorization required for i...

DefinitionInpatient video electroencephalogram (EEG): extended EEG monitoring performed in an inpatient setting.

Authorization requirementPrior authorization required for inpatient video EEG monitoring (specific CPT codes such as 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726 listed).

Outpatient exceptionPrior authorization not required for outpatient hospital or ambulatory surgical center EEG monitoring.

Durable medical equipment (DME) — Durable medical equipment (DME) - items listed in the DME code ranges require prior authorization.

DefinitionDurable medical equipment (DME): items listed in the DME code ranges require prior authorization.

Sample DME codesExamples include A9279, A9280, A9900 and numerous E-, K-, and L- codes listed in the DME/orthotics sections.

Purchase/rental notesPrior authorization required for specified DME codes and per retail purchase or rental instructions included in the document.

Enteral and in-home nutritional therapy — Enteral services and in-home nutritional therapy (enteral or gastrostomy tube) are referenced and require prior authorization when specif...

ScopeEnteral services and in‑home nutritional therapy (enteral or through a gastrostomy tube) require prior authorization when specified.

Example HCPCSEnteral supply codes include B9002 and B9998 as listed for enteral services requiring prior authorization.

Submission instructionSubmit enteral and in‑home nutritional therapy requests via the UnitedHealthcare Provider Portal or the contact numbers provided.

Home health care (outpatient) — Home health care prior authorization.

RequirementHome health care prior authorization required only in outpatient settings, including services provided in the member's home.

Example codesHome health/outpatient codes referenced include G0299, G0495, G0300, G0496, G0493, S9474, G0494.

How to obtainSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or call the phone numbers provided in the document.

UnitedHealthcare Provider Portal — Provider portal submission.

Portal submissionUse the UnitedHealthcare Provider Portal (UHCprovider.com) Prior Authorization and Notification tool with One Healthcare ID.

Phone numbersCall 844-284-0146 (general) or 888-397-8129 where referenced for injectable medication contacts.

When to use portalProviders should submit prior authorization requests online for many injectable medications and other listed services; phone alternatives available.

Unclassified/temporary HCPCS codes — Unclassified and temporary codes (C9399, J3490, J3590) — prior authorization is required only for specifically listed products (e.g., Cas...).

Unclassified/temporary codes handlingUnclassified and temporary codes C9399, J3490 and J3590 require prior authorization only for a specified set of products (e.g., Casgevy, Kebilidi, Lantidra, Lupaneta Pack, Ocrevus Pavblu, Revcovi, Rivfloza, Starjemza, Zunovo).

Optum Rx/Optum Transplant notesFor certain products, prior notification handled via Optum Rx (800-310-6826); unclassified codes may require Optum Transplant routing as described elsewhere.

Provider actionWhen billing with unclassified/temporary codes, confirm whether the specific product is listed to determine if prior authorization is required.

White blood cell colony-stimulating factors prior authorization — White blood cell colony-stimulating factor codes referenced (J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) requir...

Codes requiring prior authWhite blood cell colony-stimulating factor codes include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122.

ApplicabilityThese colony-stimulating factor codes require prior authorization for both oncology and non-oncology diagnoses; oncology requests follow the Cancer supportive care section.

Submission guidanceFor non‑oncology diagnoses, submit requests online via the UnitedHealthcare Provider Portal (UHCprovider.com) or contact the numbers provided.

Prior authorization — Prior authorization required.

Prior authorization requiredPrior authorization is required for the services, drugs, and codes listed throughout this document unless an exception (e.g., emergency/urgent care) is specified.

Where to submitSubmit requests via the UnitedHealthcare Provider Portal or by phone using the contact numbers provided in the document.

Exceptions and routingCertain items (e.g., Optum Rx prior notification for Cimzia/Synagis, Optum Transplant for unclassified codes) have special submission/routing instructions.

Private duty nursing — Private duty nursing codes.

DefinitionPrivate duty nursing codes include T1000, T1002, T1003 and require prior authorization.

Authorization requirementPrivate duty nursing prior authorization mandated before services are provided as listed in the document.

Related servicesPrivate duty nursing is listed alongside potentially unproven services and other miscellaneous codes that also require prior authorization.

Proton beam therapy — Proton beam.

ServiceProton beam therapy: focused radiation therapy using beams of protons.

Sample codesProton beam technical codes listed include 77520, 77522, 77523, 77525.

Authorization contextRadiation delivery and fractionation requests may require prior authorization to manage fractionation for specified cancer diagnosis codes.

Hypofractionation scope — Hypofractionation applicability is tied to listed ICD-10 cancer diagnosis codes (examples: bone mets, breast, prostate).

ApplicabilityHypofractionation prior authorization is tied to specific ICD-10 cancer diagnosis codes (examples include Bone Mets, Breast, Prostate lists provided).

Codes/DeliveryRadiation treatment delivery codes (e.g., 77402, 77407, 77412, 79445, S2095) have prior authorization only to manage fractionation for applicable diagnoses.

Example diagnosesApplicable ICD-10 examples include C79.51/C79.52 (Bone Mets), numerous C50.* codes (Breast), and C61 (Prostate).

VAD definition — A mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

DefinitionVentricular assist device (VAD): a mechanical pump that takes over the function of the damaged ventricle of the heart and restores normal blood flow.

Authorization requirementVAD implantation and related codes (e.g., 33976, 33983, 33979, Q0507, 33981, Q0508, 33982, Q0509) require prior authorization.

Notification processProviders should call the notification number on the member's ID card and fax required forms to Optum VAD Case Management per instructions.

CAR T-cell therapy — CAR T-cell therapy (listed generically in the policy as requiring authorization processes).

RequirementCAR T‑cell therapy services require prior authorization and include named agents such as Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, and Yescarta.

Q-code entriesListed Q‑codes (e.g., Q2041, Q2042, Q2053–Q2058) and CAR T/gene therapy entries are identified as items for which prior authorization processes apply.

Provider actionFollow the document's prior authorization routing and submission instructions for CAR T‑cell/gene therapies as specified.