CurrentColorado Rocky Mountain Health PlansPolicy N/A

Rocky Mountain Children's Health Plan — Prior Authorization

Lists prior authorization requirements, associated CPT/HCPCS and ICD-10 codes, and submission methods for participating and out-of-network providers submitting inpatient and outpatient authorization requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Rocky Mountain Children's Health Plan

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, fax to the listed numbers, or through eviCore (www.evicore.com, 800-792-8750).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprocedures & diagnoses listed

severalsubmission methods

J9000-J9999injectable chemotherapy range

manyradiology & imaging codes

37799specific code flagged

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Prior Authorization Coverage Criteria

Prior authorization requirements (selected)

Selected prior authorization requirements — the following procedures, devices, drugs, and services require prior authorization as indicated.

ALL of the following

Arthroscopy services (prior authorization required)
CPT codes: 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29875, 29876, 29877
Breast reconstruction and related procedures (prior authorization required)
CPT codes: 19328, 19330, 19340, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396
Cardiology device/procedures (prior authorization required)
Representative CPT/HCPCS codes: 33206, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229
Injectable chemotherapy and related injectable oncology agents (prior authorization required)
Includes chemotherapy injectable drugs billed J9000–J9999; specific drugs requiring prior auth include Leucovorin (J0640), Levoleucovorin (J0641, J0642), Lupron Depot (J1950), Lutetium Lu (A9607) and specified J- and Q-codes; Q-list and miscellaneous HCPCS billed chemotherapy agents also require prior authorization
Colony stimulating factors and certain biologics (prior authorization required)
Injectable medications list (selected) — representative codes requiring prior authorization include: J2778, J2327, J7352, J0802, J0223, J0896, J2357, J3399, J2782, J9072, J9286, Q5133, J2779, J1427, Q5123, J1203, J0606, J1299, J3032, J9311, Q5121, J9051, J9172, C9399*, Q5135, Q5147, Q9999, Q9997, J7170, J0174, J1823, J1442, J9345, J0717, J1429, J3241, J9312, J9324, J9052, J9255, J3490*, J1307, Q9998, Q5099, J1414, J2777, J1447, J9376, J0791, J1558, J3358, Q5115, J2765, J9064, J1552, J3590*, J2351, Q5138, Q5100, J7172, Q5148, J1072, Q5151, Q5098, Q5136, Q5152, J1954**
Notes: For unclassified/temporary codes C9399, J3490, J3590 prior authorization is required only for specified products (Amvuttra, Fylnetra, Lupaneta Pack, Recovi, Riabni, Rivfloza, Skyrizi, Steqeyma IV, white blood cell colony stimulating factors, Veopoz, Yesintek IV). For J1954, cancer diagnoses are excluded from prior authorization requirement.
Continuous glucose monitors (prior authorization required with Type 2 Diabetes diagnosis)
HCPCS/Codes: A4239, E0784, E2102, E2103
Cochlear and other auditory implants (prior authorization required)
HCPCS/Codes: 69930, L8614, L8619, L8627, L8629
Cosmetic and reconstructive procedures — cosmetic procedures generally require prior authorization; reconstructive procedures that treat a medical condition may require prior authorization
Representative CPT codes: 11960, 11971, 14020, 14021, 14060, 14061, 14301, 17106, 17107, 17108, 17999, 20930, 20931, 21141–21151, 21154–21156, 21159, 21160, 21180–21199, 21206, 21215, 21230, 21235, 21244–21256, 21275, 21280, 21282, 21295
Rhinoplasty (prior authorization required)
Skin substitutes (prior authorization required)
HCPCS/Codes: Q4117, Q4122, Q4123, Q4124, Q4126
Stimulators and neuromodulation devices (prior authorization required)
Representative CPT/HCPCS codes: 20975, 20979, 63655, 63685, 95980–95982, E0762, E0765, 64555, L8680
Surgery and select orthopedic/spine procedures (prior authorization required)
Representative CPT codes: 23473, 23474, 23472, 27130, 27132, 27134, 63200, 63250, 63252, 63265, 63267, 63268, 63270, 63271, 63272, 58570–58573, 63650
Radiology advanced imaging (prior authorization required for specified CT/MRI/MRA/PET and nuclear medicine procedures) — participating physicians should request authorization through eviCore where indicated
Representative CPT codes: 70450, 70460, 70470, 70480–70492, 70496, 70498, 70540–70546, 70547–70555, 71250, 71260, 73725, 74150, 74160
Home healthcare and durable medical equipment (DME) — prior authorization required for many DME and home health services
Representative HCPCS/Codes (selected): E0194, E0265, E0266, E0270, E0277, E0300, E2373, E2378, E2402, E2510–E2629, E2630, E8000, A9520, A9279, A9280, A9900
Enteral and in-home nutritional therapy (prior authorization required) — representative codes: B4152–B4162, B9002, B9998, S9434, S9435
Genetic testing and certain laboratory services (prior authorization required) — representative CPT/HCPCS codes include 0417U, 0018U, 0022U, 0026U, 0029U, 0047U, 0048U, 0050U, 0055U, 0094U, 0101U–0103U, 0129U, 0171U–0173U, 0179U, and various 04xxT/0412T–0422T series
Transplants and related procedures (prior authorization required)
Representative CPT/HCPCS codes: 32850–32856, 33930, 33927–33929, Q2042, Q2053, Q2055, Q2056, J3392, Q2057, J3391, Q2058, J3402
Vein procedures (prior authorization required)
Representative CPT codes: 37799 (and other saphenous vein removal/ablation procedures as listed)
Ventricular assist devices (prior authorization required)
Private duty nursing and home health services (prior authorization required)

Codes and Coding Tables

Arthroscopy CPT codesCPTCovered

29805	Arthroscopy service code listed as prior authorization required
29806	Arthroscopy service code listed as prior authorization required
29807	Arthroscopy service code listed as prior authorization required
29819	Arthroscopy service code listed as prior authorization required

Breast reconstruction CPT/HCPCS codesmixedCovered

19328	Breast reconstruction-related CPT code with prior authorization requirement
19330	Breast reconstruction-related CPT code with prior authorization requirement
L8600	Prosthetic/implant HCPCS code referenced under breast reconstruction

Cardiology CPT codesCPTCovered

33206	Cardiology device/service code listed as requiring prior authorization
33208	Cardiology code listed as requiring prior authorization
93452	Cardiac catheterization-related CPT code listed
93350	Echocardiography code listed

Selected ICD-10 diagnosis codesICD-10

C50.011	Breast cancer diagnosis code listed as not requiring prior authorization for certain post-mastectomy reconstructions
E11.52	Diagnosis code listed among those for which no prior authorization is required
I70.221	Peripheral vascular disease diagnosis code included in no-prior-auth list

Injectable chemotherapy and related agentsHCPCS

J9000-J9999	Injectable chemotherapy drugs (range) requiring prior authorization
J0640	Leucovorin
J0641	Levoleucovorin
J1950	Lupron Depot
A9607	Lutetium Lu

Cochlear implantsCPT|HCPCS

69930	Cochlear implant procedure code
L8614	Cochlear implant internal device

Selected CPT/HCPCS codes shownmixed

21159	CPT/HCPCS code referenced in listing
21160	CPT/HCPCS code referenced in listing
21206	CPT/HCPCS code referenced in listing
21740	CPT/HCPCS code referenced in listing
Q2029	HCPCS code referenced in listing

Diagnosis (ICD-10) codesICD-10

C43.0	Malignant melanoma of skin - example diagnosis code listed
C44.01	Malignant neoplasm of skin of unspecified eyelid, example diagnosis code listed

Durable medical equipment HCPCS codesHCPCS

A9520	DME HCPCS code listed
E0194	DME HCPCS code listed
E2311	DME HCPCS code listed

Enteral/In-home nutritional codesHCPCSCovered

B4149	Enteral services code listed
B4150	Enteral services code listed
B4152	Enteral services code listed
B4153	Enteral services code listed

Genetic tests/lab U-codes and molecular codesCPTCovered

0417U	Genetic test/lab code
0018U	Genetic test/lab code
0022U	Genetic test/lab code
81162	Genetic test/lab code

Hearing/audio/vision and ENT surgical codesCPTCovered

67901	Hearing/audio/vision code listed
67902	Hearing/audio/vision code listed
67903	Hearing/audio/vision code listed
69710	ENT/surgical code listed

Unclassified and exception codesHCPCS | CPT

C9399	Unclassified code - PA required only for specific drugs listed
J3490	Unclassified drug code - PA required only for specific drugs listed
J3590	Unclassified drug code - PA required only for specific drugs listed
J1954	Exclusion: Cancer diagnoses are excluded from prior auth for this code

Sample injectable medication codesHCPCSCovered

J3315
J3316
J3380
J3397
J2502
J2506
J2507

Injectable medication L-codes (sample)HCPCSCovered

L5716	L-code listed in injectable medications section
L5728	L-code listed in injectable medications section
L5811	L-code listed in injectable medications section

Radiology codes (ranges)CPTCovered

70450-70498	CT head/neck/chest/etc. range referenced for radiology prior authorization
70540-70555	MRI brain/spine ranges referenced

Sample radiology/imaging codes requiring prior authorizationCPTCovered

70543	CPT/HCPCS code listed for prior authorization
70544	CPT/HCPCS code listed for prior authorization
70545	CPT/HCPCS code listed for prior authorization
70546	CPT/HCPCS code listed for prior authorization
71250	CPT/HCPCS code listed for prior authorization
71260	CPT/HCPCS code listed for prior authorization

Sample skin substitute HCPCS codesHCPCSCovered

Q4117	Skin substitute HCPCS code listed for prior authorization
Q4122	Skin substitute HCPCS code listed for prior authorization
Q4123	Skin substitute HCPCS code listed for prior authorization
Q4124	Skin substitute HCPCS code listed for prior authorization
Q4161	Skin substitute HCPCS code listed for prior authorization

Sample stimulator/neuro codesCPTCovered

20975	Stimulator-related code requiring prior authorization
20979	Stimulator-related code requiring prior authorization
63655	Stimulator-related code requiring prior authorization
63685	Stimulator-related code requiring prior authorization
95980	Neurodiagnostic code listed for prior authorization

Selected CPT/HCPCS codes in listmixed

31240	CPT code listed for injectable medications / surgery
31253	CPT code listed
31254	CPT code listed
31255	CPT code listed
31256	CPT code listed
31257	CPT code listed
31259	CPT code listed
31267	CPT code listed
31276	CPT code listed
31287	CPT code listed

1–10 of 16

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Transplant and related codesmixed

32850	Transplant-related CPT code listed
33930	CPT code listed
38208	CPT code listed
47135	CPT code listed
50300	CPT code listed
J3393	HCPCS/J-code listed

Additional HCPCS/S/Q/J codesmixed

S2053	HCPCS S-code listed
S2060	HCPCS S-code listed
S2061	HCPCS S-code listed
S2103	HCPCS S-code listed
Q2042	HCPCS Q-code listed
J3402	HCPCS/J-code listed

Prior authorization not required — diagnosis exemptions

ICD‑10 diagnosis codes exempting post‑mastectomy reconstructionMultiple C50.* and related Z90.* codes (examples shown include C50.011, C50.012, C50.019, C50.021, C50.022) — when these diagnosis codes are present, prior authorization is not required for specified breast reconstruction procedures.

Scope of exemptionApplies to breast reconstruction codes noted in the breast reconstruction listing; exemption text appears under 'Prior Auth NOT required for diagnosis codes listed below.'

How Providers Obtain Prior Authorization

Prior Authorization

eviCore submission for specified services

Prior authorization for certain cardiology and other specialty services is managed by eviCore. Providers must submit requests online at www.evicore.com or call 800-792-8750 for review and authorization prior to providing services that fall under eviCore-managed service groups.

eviCore website: www.evicore.com
eviCore phone: 800-792-8750

Prior Authorization

Enteral services prior authorization

Enteral nutrition services (including in-home enteral therapy and related HCPCS B- and S-codes) require prior authorization. Submit requests and clinical documentation to the plan for review before initiating therapy.

Affected codes include HCPCS B4152–B4162, B9002, B9998 and S9434–S9435

Definitions and Reference Terms

Definition — Prior authorization

TermPrior authorization

Definition (context)A requirement to obtain approval before scheduled non‑emergency services or procedures; out‑of‑network providers must request prior authorization for all procedures and services.

ExemptionsPrior authorization is not required for emergency or urgent care.

Definition — Injectable chemotherapy drugs

TermInjectable chemotherapy drugs

Definition/criteriaIncludes chemotherapy injectable drugs billed under J9000‑J9999 and specified HCPCS/J codes such as J0640 (Leucovorin), J0641/J0642 (Levoleucovorin), J1950 (Lupron Depot), J0885, J1449, J1932, J1954, and A9607 (Lutetium Lu).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for Rocky Mountain Children's Health Plan

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal, fax to the listed numbers, or through eviCore (www.evicore.com, 800-792-8750).

SourceLink

On This Page

How exemption is presentedListed as 'Prior Auth NOT required for diagnosis codes listed below' in the breast reconstruction section of the policy.

Related noteExemption entries are embedded in the breast reconstruction CPT/HCPCS rows and reference the specific ICD‑10 diagnosis codes that remove the PA requirement.

Prior authorization required — DME

DME prior authorization statusDurable medical equipment (DME) items listed in the DME section require prior authorization (section states 'Durable medical equipment (DME)... Prior authorization required').

Example DME HCPCS codesA9520, E0194, E0265, E0266, E0270 are shown in the DME listing and mapped to PA instructions.

Prosthetics notePolicy clarifies 'Prosthetics are not DME - see' indicating different handling for prosthetic items versus DME.

Prior authorization required — advanced outpatient imaging

Requirement for advanced outpatient imagingAdvanced outpatient imaging procedures require prior authorization for participating physicians; requests must be submitted to eviCore (www.evicore.com) or by phone at 800‑792‑8750 before scheduling.

Scope — modalities listedCertain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures are included (examples: CPT ranges 70450‑70498, 70540‑70555 and other advanced radiology CPTs listed).

Provider responsibilityCare providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.

Prior Authorization

Genetic tests / lab services prior authorization

Genetic testing and laboratory services listed with U- and T- codes require prior authorization. Many of these tests are routed to eviCore for review; submit requests online at www.evicore.com or call 800-792-8750.

Sample affected codes: 0417U, 0018U, 0022U, 0026U, 0029U, 0047U, 0048U, 0050U, 0055U, 0419U, 0094U, 0101U, 0102U, 0103U, 0129U, 0171U, 0172U, 0173U, 0179U, 81552, 81418, 81449, 81451, 81599

Prior Authorization

Hearing / audio / vision prior authorization

Hearing, audio and vision services and related procedures (including cochlear and other auditory implants and specific ophthalmic procedures) require prior authorization. Providers must obtain authorization before scheduling these services.

Cochlear / auditory implant codes include: 69930, L8614, L8619, L8627, L8629
Hearing/audio/vision procedure examples: 67901–67908 and related V-/V5xxx codes

Prior Authorization

Orthotics and prosthetics prior authorization

Orthotics and prosthetics (L-codes shown) require prior authorization before ordering or dispensing. This includes a broad range of custom and prefabricated orthoses and prosthetic devices — verify authorization for the specific L-code prior to provision.

Examples of affected HCPCS/L-codes: L1499, L3649, L4000, L4070, L5010–L5060, L5100–L5160, L5200–L5230, L5250, L5270–L5301, L7499, L8514, L8682–L8694, L3330, L5986, L5988

Prior Authorization

Radiation therapy prior authorization

Radiation therapy (including IGRT, IMRT, proton beam and other advanced radiation services) requires prior authorization. Certain standard radiation therapy codes may require authorization when billed with specific diagnosis code ranges for malignancy.

Example CPT/HCPCS codes: 77014 (IGRT), 77385–77387 (IMRT related), G6001–G6002, 77401–77412, 79445
Standard (2D/3D) radiation therapy prior authorization required when billed with malignancy diagnoses within specified ranges (e.g., C34.*, C50.*, C61, C79.51–C79.52, D05.*)

Prior Authorization

Transplants prior authorization

Transplant procedures require prior authorization. Prior to listing, scheduling or performing transplant-related services, providers must obtain authorization from the plan.

Sample transplant procedure codes listed: 32850–32856 and related transplant procedure codes; see plan for full code list and submission instructions

Prior Authorization

Ventricular assist device prior authorization

Ventricular assist devices (VADs) require prior authorization. Providers must obtain authorization before device implantation or related services are provided.

Ventricular assist device procedural and device supply codes require review — contact the plan for specific code-level requirements and submission instructions

SettingPrior authorization required when administered in an outpatient setting for a cancer diagnosis.

Prior authorization — short definition

Short definitionPrior authorization required — many specified services, devices, medications and procedures must be authorized prior to scheduling except for emergency/urgent care.

ExamplesExamples include cochlear implants, continuous glucose monitors (with Type 2 diabetes), injectable chemotherapy, radiology and selected surgical procedures.

Submission methodsRequests submitted via UnitedHealthcare Provider Portal, eviCore, fax or phone as specified in the policy.

Prior authorization — exceptions and DME notes

Exceptions — billing with certain codesPolicy notes that prior authorization is not required when procedures are billed with specified CPT/HCPCS codes (see listing under 'Prior authorization not required when billed with the following').

DME exception/noteSimultaneously, some durable medical equipment items are explicitly flagged as requiring prior authorization in the DME list.

Diagnosis‑based exceptionsSections enumerate diagnosis codes that can exempt PA for related procedures (see breast reconstruction and dermatologic oncology listings).

eviCore — external prior authorization vendor

eviCore — roleeviCore is the external vendor used for radiology and other specified prior authorization reviews; the policy instructs providers to submit requests online at www.evicore.com or call 800‑792‑8750.

When to use eviCoreUsed for advanced outpatient imaging requests for participating physicians and for other services routed to eviCore as noted in specific sections.

Submission instruction'Please submit requests online www.evicore.com to sign in. Or, you can call 800‑792‑8750.' appears in multiple service sections.

SGP — Optum Specialty Guidance Program

SGP — Optum Specialty Guidance ProgramOptum Specialty Guidance Program (SGP) provides phone support for questions about the online authorization process for many injectable medications and related home healthcare/supply codes.

When to contact SGPContact SGP for assistance with prior authorization of injectable medications and certain home health / supply codes as referenced in the injectable medications section.

eviCore — reiterated

eviCore — referenceeviCore is referenced repeatedly as the vendor for submission and review of specified prior authorizations; providers are directed to www.evicore.com or 800‑792‑8750.

Multiple service groupseviCore handling is noted for radiology and other advanced outpatient imaging procedures for participating physicians.

Advanced outpatient imaging — referenced service group

Advanced outpatient imaging — definitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures and other advanced radiology CPT codes routed to eviCore for prior authorization.

Provider actionParticipating physicians must request authorization from eviCore prior to scheduling; care providers ordering the procedure must provide notification prior to scheduling.

Submission channelsSubmit via eviCore website (www.evicore.com) or phone 800‑792‑8750; some codes can be submitted via UnitedHealthcare Provider Portal per the radiology subsection.

Prior authorization — affirmation

FlagPrior authorization required

ApplicabilityApplies to scheduled non‑emergency services and procedures listed throughout the policy (radiology, injectables, devices, DME, surgery, etc.).

Exemption reminderEmergency and urgent care are exempt from prior authorization requirements.