CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of New York

List of services, codes, and procedures that require prior authorization for participating providers with UnitedHealthcare Community Plan of New York; includes submission methods and exceptions for emergency care. Affects participating health care professionals providing inpatient and outpatient services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of New York

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 866-362-3368.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Mar 1, 2026effective date

Requires PAelective inpatient services

866-362-3368prior auth phone

$500DME threshold

Multiplespecialty sections

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.

Coverage criteria and scope

Coverage stance and criteria examples

Covered when the following high-level rules apply:

All planned, elective inpatient service requests require prior authorization.

Prior authorization is not required for network or out-of-network emergent or urgent care.

All non-emergent, out-of-network services require prior authorization regardless of place of service.

Prior authorization required for colony-stimulating factor drugs and bone-modifying agents when administered in an outpatient setting for a cancer diagnosis (see listed J-/Q-codes).

Prior authorization required for specified cardiology outpatient and office-based diagnostic procedures and implants prior to performance.

Prior authorization coverage criteria (partial)

Partial list of services/items that require prior authorization:

Inpatient video cerebral seizure monitoring requires prior authorization (e.g., CPT 95700, 95711-95715, 95712-95713).

Injectable chemotherapy drugs administered in outpatient settings require prior authorization (J9000-J9999 and listed J-codes; miscellaneous/temporary HCPCS billed drugs also require prior authorization).

Cochlear and other auditory implants require prior authorization (examples: CPT 69710, 69714, 69930; HCPCS L8614, L8690-L8692, A4238-A4239, E2102).

Durable medical equipment (DME) listed requires prior authorization only when the retail purchase or cumulative rental cost exceeds $500 (see listed A-, E-, and other DME codes).

Prior authorization coverage notes (partial)

Selected coverage notes and examples requiring prior authorization:

Enteral and in-home nutritional services and associated gastrostomy supplies require prior authorization for listed V- and B-codes.

Erectile dysfunction procedures and related supplies/medications list multiple CPT/HCPCS codes and require prior authorization for specified codes (examples include CPT 37788, 37790, 54400-54411 series).

Femoroacetabular impingement (FAI) procedures and functional endoscopic sinus surgery (FESS) require prior authorization for the CPT codes shown (e.g., 29914-29916; 31240, 31253-31288 series).

Genetic and molecular testing (including BRCA and many panel/sequence CPT codes) requires prior authorization/notification and coordination with the ordering laboratory.

Partial coverage/authorization items (excerpt)

Additional partial indicators from the code list:

Examples

Many listed injectable medications (HCPCS J-/Q-codes) require prior authorization.
Selected surgical procedures (e.g., hysterectomy series CPT 58150–58573 and related codes) require prior authorization.

Coverage pointer

Pointer to external/related policy for newly marketed medications:

For up-to-date prior authorization and coverage guidance on newly approved drugs, providers must consult the 'Review at Launch for New to Market Medications' policy. Pre-determination is highly recommended for drugs on the Launch Medication List.

Prior authorization criteria (partial)

Submission instructions and selected prior authorization requirements (partial):

Submit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com or call the applicable phone numbers shown for specific services (examples noted in medication and procedure sections).

White blood cell colony-stimulating factors (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for both oncology and non-oncology diagnoses; oncology requests follow the cancer supportive care section, non-oncology requests may be submitted online or by phone (see chunk 110-112).

Joint, total hip and knee replacement procedures require prior authorization (see listed CPT codes in joint replacement section).

Orthotics and prosthetics L-codes listed require prior authorization only when associated with retail purchase or cumulative rental cost thresholds (see L-code list).

Prior authorization and fractionation management

Fractionation and select therapy prior authorization criteria:

Prior authorization is required for certain potentially unproven services and specified procedural categories; see listed L- and other codes for details.

Proton beam therapy (CPT 77520, 77522, 77523, 77525) requires prior authorization.

Fractionation management

Hypofractionation in scope for Bone Mets (C79.51, C79.52), Breast (C50.* series, D05.* series, C84.7A) and Prostate (C61).
Conventional fractionation in scope for Lung Cancer (C34.* series).

Prior authorization criteria and applicable diagnosis/code scope

Scope and site-of-service rules for prior authorization (diagnosis/code context):

Prior authorization to manage fractionation applies only when the requested fractionation is for the specified ICD-10 diagnoses (hypofractionation: bone mets, breast, prostate; conventional fractionation: lung cancer).

Prior authorization is required for advanced outpatient imaging procedures and many listed CPT/HCPCS codes when requested in an outpatient hospital setting; prior authorization is not required if performed at a participating ASC for those codes where noted.

Prior authorization criteria (partial list)

Procedures and device implantations requiring prior authorization (partial list):

Sleep studies require prior authorization (codes include 95805-95811, 95807-95810); note: not required for NY LTSS in the excerpt.

Spinal surgery series (examples include 22100-22633 and related spinal/neurosurgery codes) require prior authorization.

Implantable bone growth-stimulator devices and related implantation codes (examples: E0747, E0748, E0749, E0760) require prior authorization.

Prior authorization requirements by service category

Service-category prior authorization and case management requirements:

Transplant and CAR-T cell therapy services require prior authorization and coordination through the UnitedHealthcare Community and State Transplant Case Management team; call 888-936-7246 or the number on the member's ID card.

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the member ID and fax the Optum VAD Case Management form to 855-282-8929.

Vein procedures and removal/ablation codes require prior authorization (examples: 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766, 37780).

Wound vacuum therapy (e.g., E2402) requires prior authorization.

Note: Code 38232 will only require prior authorization when billed for an oncology diagnosis.

CPT / HCPCS / ICD-10 code lists

Bariatric surgery codesCPTCovered

43644	Bariatric surgery CPT/HCPCS code listed
43645	Bariatric surgery CPT/HCPCS code listed
43659	Bariatric surgery CPT/HCPCS code listed
43770	Bariatric surgery CPT/HCPCS code listed

Cancer supportive care J-codesHCPCSCovered

J1442	Filgrastim (Neupogen) — requires prior authorization for oncology and some non-oncology DX
J2506	Pegfilgrastim (Neulasta) — requires prior authorization
J1454	Akynzeo (palonosetron/fosnetupitant) — anti-emetic requiring prior authorization
J0185	Cinvanti (aprepitant) — anti-emetic
J2820	Sargramostim (Leukine)
J0897	Denosumab (Xgeva) — bone-modifying agent

Cardiovascular and related ICD-10/CPT codesmixed

93580	Cardiology-related CPT code listed
I70.221	Example diagnosis code listed as exempt from prior auth in cardiology section
M86.051	Example musculoskeletal/osteomyelitis ICD-10 codes listed

ICD-10 codes (osteomyelitis series)ICD-10

M86.272	ICD code listed in partial osteomyelitis series
M86.279	ICD code listed in partial osteomyelitis series
M86.29	ICD code listed in partial osteomyelitis series

Sample CPT/HCPCS codes requiring authorizationmixedCovered

95700	Cerebral seizure monitoring - inpatient video
95711	Cerebral seizure monitoring - inpatient video
95712	Cerebral seizure monitoring
69710	Cochlear implant code
69930	Cochlear implant code

Durable medical equipment and related HCPCS/K-codesHCPCSCovered

E1230	Example DME/prosthetic HCPCS codes listed
K0005	Example wheelchair/assistive device code listed
K0830	Example DME code listed
K0868	Example DME code listed

K-codes (equipment)HCPCS

K0852	Durable medical equipment K-code listed
K0853	Durable medical equipment K-code listed
K0854	Durable medical equipment K-code listed
K0855	Durable medical equipment K-code listed
K0856	Durable medical equipment K-code listed
K0857	Durable medical equipment K-code listed
K0858	Durable medical equipment K-code listed
K0859	Durable medical equipment K-code listed
K0860	Durable medical equipment K-code listed
K0861	Durable medical equipment K-code listed

Genetic/molecular CPT codesCPT

81162-81479 series

Genetic and molecular testing CPT codes (BRCA and other panels/sequencing)

Temporary (U-) and miscellaneous codesmixed

0307U
0318U
0319U
0320U
0326U
0334U
0355U
0364U
0378U
0379U

1–10 of 27

1/3

Hysterectomy and related gynecologic CPT codesCPT

58150	Hysterectomy (example listed)
58152
58180
58260
58262
58263
58267
58270
58275
58290

1–10 of 24

1/3

Home health/outpatient G-codesCPT|HCPCS

G0156	Home health care
G0162	Home health care
G0299
G0300
G0493
G0494
G0495
G0496

Selected injectable HCPCS/J-codes (partial list)HCPCSCovered

J1745	Remicade
J0177	Eylea HD
J1555	IVIG codes referenced
J2357	Xolair
J0256	Aralast NP / Prolastin-C / Zemaira referenced in list
J3399	Zolgensma (listed as J3399 in one chunk)
J9202	Zoladex
Q5100	Yesintek IV
Q5101
Q5121	Avtozma

mentioned HCPCS/CPT codes (partial)HCPCS

J2357	Xolair (mentioned)
Q5100	Yesintek IV / Zemaira (mentioned)
J0256	Zemaira / Zoladex (mentioned)
J9202	Zoladex / Zolgensma (mentioned)
J3399	Zolgensma (mentioned)

Referenced HCPCS/drug codesHCPCS|mixed

J3399	HCPCS code referenced multiple times in this section
Zolgensma	product name mentioned alongside J3399

Joint replacement CPT codes (partial)CPTCovered

24360	Joint replacement — listed CPT code (partial list)
27120	Total hip replacement (example from list)
27486	Knee replacement (example from list)

Orthotics/Prosthetics HCPCS L-codes (partial)HCPCSCovered

L0112	Orthotic/prosthetic supply code (example)
L3905	Orthotic/prosthetic supply code (example)

Sample L-series HCPCS codesHCPCS

L3961	HCPCS L-code listed
L3971	HCPCS L-code listed
L3975	HCPCS L-code listed
L5976	HCPCS L-code listed
L5999	HCPCS L-code listed
L6000	HCPCS L-code listed

Radiation therapy CPT/HCPCS codesCPTCovered

77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy
77525	Proton beam therapy
77402	Radiation treatment delivery
77407	Radiation treatment delivery
77412	Radiation treatment delivery
77371	SRS/SBRT
77372	SRS/SBRT
77373	SRS/SBRT

1–10 of 12

1/2

Private duty nursing codesHCPCSCovered

T1000	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing

Hypofractionation ICD-10 codes (bone mets, breast, prostate)ICD-10Covered

C79.51	Secondary malignant neoplasm of bone
C79.52	Secondary malignant neoplasm of bone
C50.*	Malignant neoplasm of breast (multiple specific codes listed)
D05.*	Carcinoma in situ of breast (multiple specific codes listed)
C84.7A	Mycosis fungoides (specific subcode listed in document)
C61	Malignant neoplasm of prostate

Conventional fractionation ICD-10 codes (lung cancer)ICD-10Covered

C34.*

Malignant neoplasm of bronchus and lung (multiple specific codes listed)

Representative CPT/HCPCS codes requiring prior authorization (full list in document)mixedCovered

0697T	Radiology advanced imaging (example T-code listed)
0712T	Radiology advanced imaging (example T-code listed)

ENT and related procedures (partial list)CPT

20552	ENT procedure (listed)
20553	ENT procedure (listed)
21012	ENT procedure (listed)
21013	ENT procedure (listed)
21336	ENT procedure (listed)

Sleep, spinal, stimulators, neurosurgery (partial list)mixed

95805-95811	Sleep study codes (polysomnography)
22100-22633	Spinal surgery code series (examples listed)
63001-63308	Neurosurgical/spinal fusion and related codes (examples listed)
0095T, 0098T, 0164T	Category III (example codes listed)
E0747, E0748, E0749, E0760	Durable medical equipment / bone growth-stimulator
63650-63655	Spinal cord stimulator codes

Bone growth-stimulator / implantable device codesHCPCS

E0747	Implantation of a device that sends electrical impulses (bone growth-stimulator)
E0748	Implantation of a device that sends electrical impulses
E0749	Implantation of a device that sends electrical impulses
E0760	Implantable device code listed

Transplant and CAR-T related codesmixed

38232*	Stem cell harvest code — noted: will only require prior authorization for an oncology diagnosis
J3387	Drug/admin code listed under transplants/CAR-T section
Q2041	Billing code listed under transplant/CAR-T section

Vein procedure codesCPTCovered

36473	Vein procedure code
36475	Vein procedure code
36478	Vein procedure code
37700	Vein procedure code

Wound VAC codeHCPCSCovered

E2402

Wound vacuum device

Cancer outpatient injectable requirement

RequirementPrior authorization is required for colony-stimulating factor drugs and bone-modifying agents administered in an outpatient setting for a cancer diagnosis (examples: J1442, J2506, J0897).

Submitting prior authorization and required actions

Prior Authorization

How to submit prior authorization requests and general rules

Submit prior authorization (PA) requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal at UHCprovider.com (Sign In with One Healthcare ID → Prior Authorization and Notification tab). When online submission is not possible, call the number on the member’s ID card or the general PA contact numbers published in the plan communications.

All planned elective inpatient services require prior authorization.
Prior authorization is not required for emergent or urgent care.
All non‑emergent out‑of‑network services require prior authorization.

Prior Authorization

Cardiology prior authorization contacts

For cardiology-specific prior authorization guidance and the detailed CPT list used for cardiology PA/notifications, use the Cardiology Prior Authorization and Notification resources on the Provider Portal or call the PA phone numbers listed on the portal / member ID card.

Definitions and terms

Definition — Prior authorization

DefinitionPrior authorization is the requirement to obtain approval from the health plan before providing certain planned/elective inpatient services or specified outpatient procedures and drugs.

When requiredAll planned, elective inpatient service requests require prior authorization; emergent/urgent care does not.

How to confirmSubmit requests via the Prior Authorization and Notification tool on UHCprovider.com or call the plan's prior authorization phone number.

Durable medical equipment (DME) prior authorization threshold

ThresholdDME prior authorization applies only to listed DME codes when retail purchase or cumulative rental cost exceeds $500.

Sample codes subject to threshold

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of New York

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or call 866-362-3368.

SourceLink

On This Page

Examples (codes)Filgrastim (Neupogen) J1442; Pegfilgrastim (Neulasta) J2506; Denosumab (Xgeva) J0897.

Non-oncology noteCodes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120 and Q5122 also require prior authorization for non-oncology diagnoses.

Where to checkSee the injectable medications section and the Launch Medication List guidance for related prior authorization rules.

DME prior authorization cost threshold

ThresholdDME prior authorization is required only for listed DME codes with a retail purchase or cumulative rental cost greater than $500.

Examples (sample DME codes)A4575, A9279, A9280, A9900, E0194, E0265, E0277, E0445.

ScopeApplies to durable medical equipment codes explicitly listed in the DME section; prosthetics are not classified as DME here (see orthotics/prosthetics section).

HCPCS/CPT codes (examples)

Representative injectable J/Q codesJ2357 (Yesintek IV), J0256 (Zemaira), J9202 (Zoladex), J3399 (placeholder for Zolgensma), Q5100 (Yesintek IV).

Selected biologic/other injectablesJ1745 (Remicade), J1555 (IVIG codes), J2357 (Xolair), J0256 (Zemaira).

Chemotherapy injectables groupChemotherapy injectable drugs (J9000–J9999) and certain miscellaneous or Q-coded injectables require prior authorization for outpatient administration.

See portal Cardiology Prior Authorization and Notification for the full CPT listing (example code shown: 93580).

Call the PA contact on the member’s card for case-specific assistance.

Prior Authorization

Services listed requiring prior authorization

The plan requires prior authorization for a broad set of services. Providers must obtain PA before performing the listed outpatient procedures, durable equipment purchases above thresholds, selected injections and specialty drugs, genetic and advanced molecular testing, many surgical procedures (including joint replacement and orthognathic surgery), home health (outpatient), private duty nursing, proton beam and certain radiation fractionation requests, transplants/CAR‑T, VADs, wound VACs, cochlear and other auditory implants, and many others listed below. When a code is included, PA is required for that code as shown.

Bariatric surgery — examples: 43644, 43645, 43659, 43770.
Cancer supportive care / oncology injectables — J9000–J9999 and listed colony‑stimulating factors (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122).
Cardiovascular outpatient diagnostic catheterizations, echocardiograms, electrophysiology implants — PA required before performance.
Chemotherapy injectable drugs (outpatient) — PA required; includes J9000–J9999, Leucovorin J0640, Levoleucovorin J0641/J0642, and miscellaneous/Q‑codes.
Cochlear and other auditory implants — e.g., 69930, L8614, L8690, L8691.
Durable Medical Equipment (DME) — PA required only for codes with retail purchase or cumulative rental cost > $500 (examples: A4575, A9279, A9280, A9900, E0194, E0265…).
Enteral / in‑home nutritional services — PA required; example HCPCS mapping: V5286→B4034 / B4102 etc.
Erectile dysfunction services — PA required for listed procedure and drug codes (examples: 37788, 54400–54417, 55870; J0270, J0275, J0775, J2440, J2760; L7900, L7902).
Genetic and molecular testing (including BRCA and other panels) — PA required for many CPT codes (examples: 81162–81164, 81228–81277, 81415–81448 and additional advanced/genomic U‑codes and S‑codes listed separately).
Home health care — PA required in outpatient settings only; example codes: G0156, G0162, G0299, G0300, G0493–G0496, S5170, S9122–S9124, S9474.
Joint replacement (total hip/knee) — PA required for many CPT/HCPCS and supply codes (examples listed in joint replacement section: 24360–24371 series, 27120–27138 series, 27412, 27446–27487, 29866–29868, J7330, S2112).
Orthognathic surgery — PA required for broad series of CPT codes (examples: 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, 21188–21215, 21240–21249, 21255, 21296, 21299).
Orthotics and prosthetics — PA required only for listed L‑codes with retail/cumulative rental cost above threshold (selected examples: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700–L1730, L1755, L1820, L1832, L1834, L1840, L1844–L1846, L1860, L1945, L1950, L1970, L2000–L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627–L2628, L3230, L3265, L3649, L3671, L3674, L3720–L3764, L3900–L3905, L3961–L4020, L4631, L5010–L5560 series).
Potentially unproven / investigational procedures — PA required (examples include certain L‑code mappings and S‑codes; see investigational entries).
Private duty nursing — PA required; example codes: T1000, T1002, T1003.
Proton beam therapy and radiation therapy — PA required; PA may be used to manage fractionation for specific cancer diagnosis codes (see fractionation block). Examples: 77520, 77522, 77523, 77525 and related radiation service codes (77331, 77370, 77399, 77470, Y90, S2095, 79445).
Radiology advanced imaging (certain CT/MRI/MRA/PET and nuclear medicine) — PA required for the listed advanced outpatient imaging HCPCS/T‑codes (examples: 0697T, 0710T–0712T).
Sleep studies and sleep apnea procedures/surgeries — PA required (examples: 21685, 41599, 42145; sleep study codes 95805, 95807–95811; LTSS exceptions apply as noted).
Spinal and other major surgeries — numerous CPT series require PA as listed across the surgical sections.
Transplants and CAR‑T therapies — PA required; contact UnitedHealthcare Community and State Transplant Case Management at 888‑936‑7246 or the number on the member’s ID card.
Ventricular Assist Devices (VAD) — PA required; notify per ID card and fax required documentation to Optum VAD Case Management at 855‑282‑8929.
Wound VAC therapy — PA required; example HCPCS: E2402.
Zolgensma / new high‑cost drugs billed to J3399 or unclassified codes — check the Launch/New‑to‑Market medication policies and the plan’s specialty drug lists for current PA requirements and contacts.

Prior Authorization

Prior authorization — advanced/genomic test codes (U-codes and S-codes)

Use the Provider Portal PA tool for genetic, molecular, and advanced genomic tests; many U‑codes and S‑codes for novel genomic assays require prior authorization. A non‑exhaustive list of advanced/genomic U‑codes requiring PA is maintained by the plan and includes (examples): 0233U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0250U, 0258U, 0265U, 0268U, 0269U, 0270U–0274U, 0276U–0289U, 0290U–0306U.

PA required for listed U‑codes and many S‑codes — verify current list on the Provider Portal.
Testing requests follow the plan’s genetic testing prior authorization/notification process; some tests require pre‑authorization review and clinical documentation.

Note

Prior authorization notices (partial)

Important prior authorization notices and operational points providers must observe.

For unclassified and temporary codes (C9090, C9149, C9151, C9166, C9399, J3490, J3590), PA may be required only for specific named products — check the Launch Medication List.
For new‑to‑market medications billed to J3399 (or similar), review the plan’s Launch/New‑to‑Market Medications policy — pre‑determination is highly recommended.
Certain colony‑stimulating factors and white blood cell growth factors require PA for oncology and non‑oncology diagnoses — see cancer supportive care and injectable medication guidance.

Prior Authorization

Home health prior authorization note

Home health services require prior authorization when provided in outpatient settings (including the member’s home) — outpatient home health PA applies to the CPT/HCPCS codes listed below. Do not assume PA is needed for facility‑based home health programs not described here; verify by benefit.

Home health (outpatient) — PA required only in outpatient settings. Example codes: G0156, G0162, G0299, G0300, G0493–G0496, S5170, S9122–S9124, S9123, S9124, S9474.
Obtain PA via the Provider Portal Prior Authorization and Notification tool or by calling the PA phone number on the member’s ID card.

Documentation Required

Partial CPT/HCPCS code list and prior authorization placeholders

This is a partial list of CPT/HCPCS and HCPCS‑like codes that commonly trigger PA and are used as placeholders in the plan’s code lists. Always confirm the applicable list on the Provider Portal for the complete and current coding tables. The plan also maintains crosswalks for L‑codes, U‑codes, S‑codes, and unclassified drug codes.

Sample DME codes (PA threshold applies if retail/cumulative rental > $500): A4575, A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471, E0483, E0486, E0620, E0636–E0638, E0641–E0656.
Genomic / advanced test placeholders: U‑codes (examples listed in advanced/genomic block) and S‑codes.
High‑cost drug placeholder: J3399 (Zolgensma / newly launched therapies) — see Launch policy for details.

Prior Authorization

Cross-reference placeholder for Zolgensma prior authorization

Zolgensma and other newly marketed, very high‑cost therapies are managed via the plan’s specialty/launch medication review process. Zolgensma billing may appear under J3399; providers must check the plan’s Launch/New‑to‑Market Medications policy and specialty drug lists on the Provider Portal for current PA requirements and submission instructions.

Zolgensma — billing placeholder J3399; confirm PA and process on the Launch policy.
For new specialty drugs, pre‑determination and PA are highly recommended prior to administration or shipment.

Documentation Required

Prior authorization / coding references

Coding and prior authorization references and operational guidance used by the plan.

Review the Launch Medication List and Review at Launch for New to Market Medications policy for current requirements on newly approved drugs.
Unclassified and temporary codes (e.g., C9090 series, J3490, J3590) may have selective PA requirements — check product‑specific guidance.
Most PA requests should be submitted via the Provider Portal Prior Authorization and Notification tool; phone numbers are provided for cases that require verbal submission or clarification.

Prior Authorization

Prior authorization required — orthotics and prosthetics (selected L‑codes)

Prior authorization is required only for orthotics and prosthetics L‑codes listed with a retail purchase or cumulative rental cost above the plan threshold. Providers should confirm cost thresholds and submit clinical justification and purchase/rental cost details with the PA request.

Selected L‑codes requiring PA (non‑exhaustive examples): L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700–L1730, L1755, L1820, L1832, L1834, L1840, L1844–L1846, L1860, L1945, L1950, L1970, L2000–L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627–L2628, L3230, L3265, L3649, L3671, L3674, L3720–L3764, L3900–L3905, L3961–L4020, L4631, L5010–L5560 series.
Include retail purchase price or cumulative rental cost documentation with the PA submission; submit via the Provider Portal or the PA phone contact if required.

Prior Authorization

Private duty nursing prior auth

Private duty nursing services require prior authorization. Submit PA requests with clinical justification, expected hours of care, and service setting. Contact the plan for case management coordination when applicable.

Example CPT/HCPCS codes triggering PA: T1000, T1002, T1003.
Private duty nursing PA is required prior to initiation of ongoing services.

Prior Authorization

Site-of-service prior authorization rule

Site‑of‑service (SOS) rule: prior authorization is required when the plan member’s outpatient procedure is requested to be performed in an outpatient hospital setting (facility site). If the same procedure is performed at a participating ambulatory surgery center (ASC), PA is not required solely for site‑of‑service. Providers must request PA if they are seeking outpatient hospital setting reimbursement for codes designated under the SOS rule.

Examples of codes subject to SOS PA when performed in an outpatient hospital: selected cardiovascular, ENT and orthopedic procedures (see outpatient hospital / SOS lists).
If procedure will be done at a participating ASC, PA for site of service is not required.

Prior Authorization

Prior authorization for fractionation by diagnosis

Fractionation management: prior authorization may be required to manage radiation fractionation when requested for specific cancer diagnoses (hypofractionation management). The plan lists applicable ICD‑10 diagnosis codes for bone metastases, breast cancer, prostate cancer and other tumor types that fall within hypofractionation scope. When requesting non‑standard fractionation (hypofractionation) for the listed diagnoses, include the cancer diagnosis ICD‑10 codes and the proposed fractionation schedule in the PA request.

Hypofractionation applicable diagnosis examples (partial): Bone Mets — C79.51, C79.52; Breast — extensive list of C50 series and D05.* codes (see plan list).
Conventional fractionation diagnostic examples include lung cancer ICD‑10 series (C34.xx) per the plan guidance.
Include proposed schedule and clinical rationale for fractionation requests; PA may be required only when fractionation management is requested.

A4575, E0445, E0457, E0465, E0470, E0620 (examples from DME list).

Exclusion noteProsthetics are noted as not DME — see the orthotics and prosthetics section for separate rules.

Prior authorization submission method

Primary submission methodOnline via the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com Prior Authorization and Notification tab).

Phone alternativesCall the listed prior authorization numbers (examples in document: 866-362-3368; oncology/non-oncology contacts such as 888-397-8129 or 877-842-3210 are referenced depending on service).

NotesPre-determination is highly recommended for Launch Medication List drugs; specific products (e.g., Cimzia) require Magellan prior notification at 800-788-4005.

Prior authorization (term)

TermPrior authorization / prior notification — an approval the plan requires before performing listed procedures, genetic testing, or administering certain medications.

Usage examplesUsed repeatedly in the document to denote required approval for surgical procedures, genetic/molecular testing, and injectable medications.

Provider responsibilityOrdering providers must follow notification/authorization steps (e.g., notify laboratory for genetic testing) as indicated.

Genetic and molecular testing — process note

Process noteGenetic and molecular testing (including BRCA and other sequencing/panel tests) require prior authorization/notification; ordering provider must notify the laboratory performing the test.

Example codesGenetic testing CPT examples include 81162, 81163, 81164, 81228, 81229 and other 81162–81479 series codes listed.

ActionFollow prior authorization/notification instructions in the genetic and molecular testing section before submitting specimen to the lab.

Gender dysphoria treatment definition

DefinitionGender dysphoria treatment includes listed surgical procedure codes and requires prior authorization when associated with the specified diagnosis codes (F64.x series).

Associated diagnosis codesExamples referenced include F64.0, F64.1, F64.2, F64.8, F64.9 and related DX mapping.

Provider actionObtain prior authorization for the surgical codes associated with gender dysphoria treatment per the document's instructions.

Home health care (outpatient) definition

DefinitionHome health care (outpatient) prior authorization is required only when services are provided in outpatient settings such as the member's home.

Example G-codesG0156, G0162, G0299, G0300, G0493–G0496 are listed for home health/outpatient services.

ScopeThis outpatient-only prior authorization requirement applies to home health services referenced in the document.

Review at Launch for New to Market Medications

Policy referenceReview at Launch for New to Market Medications — providers must consult this policy for up-to-date prior authorization and coverage guidance on newly approved drugs.

Action recommendedPre-determination is highly recommended for drugs on the Launch Medication List per document guidance.

Where mentionedDocument repeatedly instructs providers to 'Please check our' and refer to the Review at Launch policy for new drugs (see multiple chunks).

Pre-determination recommendation for Launch Medication List

RecommendationPre-determination is highly recommended for drugs on the Launch Medication List.

Submission noteFor drugs requiring pre-determination or special review, follow the Launch Medication List process described in the referenced policy.

ExamplesCertain unclassified/temporary codes and high-cost new drugs may require pre-determination; see the Launch Medication List for details.

Magellan prior notifications for Cimzia

Magellan prior notification (Cimzia)Obtain prior notification for Cimzia through Magellan prior notifications services at 800-788-4005.

How notedDocument explicitly instructs providers to obtain Cimzia prior notification via Magellan at the listed number.

Related submissionOther biologics and specialty drugs on the Launch Medication List may have separate notification routes; follow the Launch policy as referenced.

Proton Beam Therapy definition

DefinitionProton Beam Therapy (PBT): focused radiation therapy using beams of protons; specific CPT codes listed (77520, 77522, 77523, 77525) and prior authorization is required.

Applicable CPT codes77520, 77522, 77523, 77525.

Authorization noteProton beam therapy is explicitly noted as requiring prior authorization in the radiation therapy section.

Applicable ICD-10 codes for fractionation

Hypofractionation ICD-10 groupBone Mets: C79.51, C79.52; Breast: multiple C50.* and D05.* codes (detailed list in document); Prostate: C61. Prior authorization may be required to manage fractionation for these diagnoses.

Conventional fractionation ICD-10 groupLung cancer: C34.00–C34.92 range listed for conventional fractionation prior authorization considerations.

PurposePrior authorization is required only to manage fractionation when requested for the listed ICD-10 diagnosis codes/ranges.

Site of service (SOS) definition

DefinitionSite of service (SOS) — designation of the intended place of service (example: outpatient hospital). Prior authorization is required in some cases when requesting service in an outpatient hospital setting.

Rule examplePrior authorization is only required when requesting service in an outpatient hospital setting; not required if performed at a participating ASC for specified procedures.

Example codes tied to SOSArthroscopic shoulder/arthroscopy codes (29877–29893) and G0260 are listed with outpatient hospital SOS notes.

Fractionation (hypofractionation/conventional) definition

Fractionation categoriesHypofractionation: applies to Bone Mets, Breast, Prostate ICD-10 codes; Conventional fractionation: applies to Lung cancer ICD-10 codes.

When PA is neededPrior authorization is required only to manage fractionation when requested for the specified diagnosis codes/ranges.

Related servicesAssociated radiation CPT/HCPCS codes and special/associated services are listed in the radiation therapy section.

Prior authorization term (examples)

Examples of term use'Prior authorization' is used to indicate required approvals for planned inpatient services, outpatient injectables (chemotherapy J9000–J9999), and many listed procedures (e.g., joint replacement).

Submission reminderProviders are repeatedly instructed to submit prior authorization requests online via UHCprovider.com or call the applicable phone numbers shown in the document.

ScopeTerm applies across sections for surgical procedures, device implantation, advanced imaging, genetic testing, and specialty medications.

Site of service (SOS) example

ExampleSite-of-service example: outpatient hospital — prior authorization is required when requesting service in an outpatient hospital setting for certain procedures (not required if performed at a participating ASC).

Codes shown with SOSExamples include arthroscopic codes 29877–29893 and G0260 noted with outpatient hospital SOS.

Practical noteVerify site-of-service requirement when submitting prior authorization for advanced outpatient procedures to determine if PA is necessary.

Ventricular assist devices (VAD) definition

DefinitionVentricular assist devices (VAD) — a mechanical pump that takes over heart function; VAD placement and related services require prior authorization.

Provider actionCall the notification number on the back of the member's health plan ID card and fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.

PA requirementPrior authorization is explicitly required for VADs per the document's VAD section.

Transplant/CAR-T definition

DefinitionTransplant/CAR-T — services for transplant and CAR T-cell therapies require prior authorization and coordination via UnitedHealthcare Community and State Transplant Case Management.

ContactCall the Transplant Case Management team at 888-936-7246 or the number on the back of the member's health plan ID card for authorization and coordination.

ScopeIncludes multiple CAR-T products and related billing codes listed in the transplant section of the document.