Coverage notes: The following services and code groups require prior authorization or notification as indicated. Where program-specific instructions or vendor contacts apply (e.g., Optum Transplant, Optum VAD Case Management), providers must follow those enrollment/notification processes and use the contact numbers/forms noted.
Radiology: Prior authorization is required for participating physicians for certain advanced outpatient imaging procedures (CT, MRI, MRA, PET, nuclear medicine, and specified advanced imaging). Providers should request prior authorization for those studies per the health plan process.
Genetic testing / BRCA: Prior authorization or notification is required for specified genetic tests (including BRCA) before DNA sequencing or testing is performed. The ordering provider must notify the laboratory and the laboratory will notify the plan/vendor as required. Specific CPT/HCPCS codes listed in the genetic testing code groups require prior authorization.
Transplants and CAR T-cell therapies: Prior authorization is required for transplant and transplant-related services and for specified CAR T-cell and gene therapy services. For transplant and CAR T-cell therapy services (including Carvykti, Kymriah, Yescarta) providers must call Optum at 888-936-7246 or use the number on the member ID card. Effective dates: unclassified J-codes (J3490, J3590) required prior authorization through Optum Transplant effective July 1, 2024; certain therapies (e.g., Aucatzyl) require prior authorization effective April 1, 2025.
Ventricular assist devices (VAD): Prior authorization is required (e.g., 33927, 33928, 33929, Q0507). Providers must call the number on the member's health plan ID card and then fax the nurse-provided form to the Optum VAD Case Management team at 855-282-8929.
Remote patient monitoring: Prior authorization is required for remote patient monitoring services — examples include codes 98975, 98976, 98977, 98980, 98981.
Urine drug testing: Prior authorization is required for specified urine drug testing codes (e.g., G0482, G0483).
Durable medical equipment (DME) and Prosthetics: Prior authorization is required for listed DME/HCPCS codes and for retail purchases or cumulative rental costs above plan-specified thresholds (examples: E0265, E0266, A9279, E0277, E0296–E0304, E0328–E0339, E0439, E0442–E0457). Prosthetics are not DME — see orthotics/prosthetics policy as applicable.
Bariatric and behavioral health: Prior authorization is required for bariatric surgery (codes include 43644, 43645, 43659, 43770) with a Center of Excellence requirement for bariatric coverage. Behavioral health services may require prior authorization and some benefit plans administer behavioral health through a designated behavioral health network — call the number on the member's ID card for referral and PA requirements.
Surgical procedures and others: Prior authorization is required for many elective and higher-cost procedures including hysterectomy (e.g., 51925, 58152, 58200, 58210), rhinoplasty (30400–30430 range), spinal surgery (e.g., 22856, 22860, 22867, 22868), stimulators (e.g., 61885, 61886, 63650, 63685, 64555), transplants and organ/tissue transplant-related services (e.g., 44136, 44137, 44715, 44720, 44721, 38230, 47135), wound vac (E2402), ventricular assist devices, and others as listed in code groups.
Gene therapy and unclassified J-codes: Gene therapy services and unclassified J-codes (J3490*, J3590*) require prior authorization; Lenmeldy and other specific therapies follow the Optum Transplant prior authorization process where noted.
Provider operational note: When a vendor or program is listed (for example Optum Transplant or Optum VAD Case Management), providers must use the vendor-specific prior authorization process and forms and adhere to effective dates listed for specific code requirements.