CurrentColorado Rocky Mountain Health PlansPolicy N/A
Prior authorization and notification requirements for participating providers
Governs prior authorization and notification requirements for participating UnitedHealthcare Mid-Atlantic Health Plans providers for specified inpatient and outpatient procedures and services; describes submission methods and rules about emergency, urgent, in-network and elective services.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization and notification requirements for participating providers
Policy CodePolicy N/A
Change TypeAdministrative review — no material changes
Effective DateSep 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or 24/7 chat; obtain authorization before elective services.
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.
explicit 'PA required' areas
manylisted CPT/HCPCS/ICD codes
Coverage Criteria and Prior Authorization Requirements
Prior authorization coverage criteria (partial)
Prior authorization required for the listed procedures and codes; exceptions and additional requirements are noted for specific services.
Prior authorization is required for the CPT/HCPCS procedure codes listed below before elective services are performed; emergency or urgent care is exempt.
Examples of procedure groups requiring prior authorization
BRCA/genetic testing examples: 81162, 81163, 81164, 81277, 81349 and related U-codes listed in the document (provider attestation required)
Providers must submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat; out-of-network providers must request prior authorization for all procedures and services.
Prior authorization requirements and exceptions (partial)
Partial criteria and stances extracted from this section:
Injectable chemotherapy and supportive oncology agents administered in an outpatient setting require prior authorization (includes chemotherapy J-codes J9000-J9999, Leucovorin J0640/J0641/J0642, Leuprolide J1950/J1952, Lanreotide J1932 and listed colony-stimulating factor codes such as J1449, J1442, J1447, J2506, Q5101, etc.).
Exceptions
Prior authorization is not required for the specific diagnosis codes listed in the document (examples shown under D05.x and Z90.x series).
Some HCPCS/J-codes are annotated in the policy (e.g., *) indicating additional notes or oncology-specific handling; follow the oncology supportive care subsection for details.
Fragment-level coverage requirements
Selected coverage/authorization stances for codes appearing in this fragment:
Cartilage implant procedures require prior authorization (examples: CPT 27412, 27415, 27416, arthroscopic related 29866-29868) and related supply/drug codes J7330 and S2112 are listed for authorization.
Inpatient video EEG monitoring codes require prior authorization for inpatient services (examples: 95700, 95711-95713, 95715-95716, 95718); outpatient EEG monitoring does not require prior authorization.
Injectable chemotherapy drugs and certain oncology injectables require prior authorization when administered in an outpatient setting (includes J9000-J9999, J0640-J0642, J1932, and Q-code chemotherapy drugs).
Congenital heart disease and ventricular assist device (VAD) related procedures require prior authorization; providers are instructed to contact the Optum VAD Case Management Team (see VAD contact guidance).
Authorization requirements (partial)
Prior authorization requirement for cosmetic/reconstructive procedures
Cosmetic and reconstructive procedures listed in the policy require prior authorization in all states (examples include CPT 11960, 11970-11971, 14020*, 14021*, 14061*, 14302, 15570, 15572, 15574, 15730, 15733, 15740, 15756, 15769, 15773, 15820-15823, 15830, 15847, 15877-15879, 17999, 21137-21139).
Continuous glucose monitor supplies/devices require prior authorization when used for type 2 diabetes (device HCPCS examples appear in the device section).
For VAD-related items coded L8692, providers should contact Optum VAD Case Management or use the notification number on the member ID card for prior authorization/notification (see VAD guidance).
Prior authorization coverage criteria (partial)
Coverage stance and prior authorization requirements for listed services and codes (partial).
Prior authorization required for the listed cosmetic/reconstructive CPT/HCPCS codes; site-of-service will be reviewed as part of prior authorization and specified state/territory exceptions apply (AK, MA, PR, RI, TX, UT, VI, WI).
DME and prosthetics: prior authorization is required for listed DME/prosthetics codes only when retail purchase or cumulative rental cost exceeds $1,000; certain devices (e.g., specified lymphedema pumps) require prior authorization regardless of cost; prosthetics are not treated as DME for this threshold.
End-stage renal disease (ESRD) dialysis services (examples: CPT 90935, 90937, 90945, 90947, 90999; HCPCS S9335, S9339; J-codes J0606, J0879) require prior authorization; providers should request authorization via the payer's 24/7 chat Contact Us page.
Certain CPT 1710x codes are not subject to prior authorization when billed with specified diagnosis codes as listed in the policy (see diagnosis-linked exceptions section).
Prior authorization criteria and submission instructions (partial list from document chunks)
Prior authorization requirements and submission instructions for listed services and codes
Surgical and procedure categories
Foot surgery codes (examples: 28289-28299) require prior authorization; site-of-service will be reviewed with jurisdictional exceptions.
Hysterectomy and infertility-related procedures require prior authorization (examples: 58150, 58152, 58267, 58270, 58292, 58294; infertility services and related codes listed).
Home health non-nutritional in-home services require prior authorization (examples: T1000, T1002, T1003).
Prior authorization coverage criteria (excerpt)
Services and codes that require prior authorization and related special conditions
MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid requires prior authorization (examples: 0071T, 0072T); member coverage confirmation and contracted facility required; member must provide written consent acknowledging limited evidence and agreement not to hold payer responsible for unsatisfactory results.
Non-emergency air transport (examples: A0430, S9960, A0431, A0435, A0436) requires prior authorization.
Prior authorization and notification of admission date are required for specified post-acute inpatient facilities (acute care hospital, inpatient rehab, LTAC, SNF) before admission when applicable.
Prior authorization is required for specified service categories and codes; submission routes vary by service type.
Out-of-network referrals: when a network provider directs a member to an out-of-network facility/provider and the member's plan allows out-of-network benefits, prior authorization is required; members may have increased out-of-pocket costs.
Therapy (PT/OT/SLP): initial referral valid up to 8 visits per condition within 6 months; prior authorization requests for therapy cannot be submitted online and must be faxed to Clinical Care Coordination at 888-831-5080 using the Rehabilitation Services Extension Request Form.
Radiation therapy and radiology services require prior authorization for many listed CPT/HCPCS codes (examples include SRS/SBRT 77371, standard radiation therapy codes 77401-77499 where indicated); submit via the Provider Portal Prior Authorization and Notification tool for Radiology/Cardiology/Oncology/Radiation Therapy.
Prosthetics: prior authorization is required for many prosthetic codes when retail purchase or cumulative rental cost exceeds $1,000; follow specialty submission instructions where noted.
Prior authorization coverage criteria examples
Coverage stance and requirements referenced in this segment (examples):
Rhinoplasty for treatment of nasal functional impairment and septal deviation requires prior authorization (CPT examples: 30400, 30410, 30420, 30430).
Spinal cord stimulator implantation for pain management requires prior authorization in all states (examples include CPTs 63650, 63655, 63662, 63664, 63685, 63688 and HCPCS supplies L8679, L8680, etc.); site-of-service review applies with state exceptions noted elsewhere in the policy.
Spinal surgery procedures require prior authorization for all states with extensive CPT lists provided (examples include 20930, 22513, 22859, 63005); site-of-service will be reviewed for certain codes.
Organ/tissue transplant and transplant-related services (including pre-treatment/evaluation and bone-marrow harvest) require prior authorization; cellular and gene therapy services require prior authorization/notification and provider contact instructions are provided.
Prior authorization/coverage stance for listed services
Stance and criteria inferred from this section
Prior authorization is required for listed organ/tissue transplant-related services and related pre-treatment or evaluation codes (examples: 38240-38242, S2150, 33930, 33940, 33944-33945).
Prior authorization is required for listed bone-growth stimulator HCPCS codes (E0747, E0748, E0749, E0760) and associated CPT mappings as specified in the policy.
Cellular and gene therapy services (named products and mapped J/Q codes) require prior authorization/notification; providers are instructed to call the specified contact number (Optum/notification number on member ID) for these therapies.
Vein procedures (removal and ablation of saphenous veins and named branches) mapped to HCPCS A95xx/A96xx and CPT codes (e.g., 36470-36479, 37243, 37700, 37718, 37722) require prior authorization.
Prior authorization requirement
Administrative note: prior authorization is required for the listed procedure codes.
Ventricular assist devices (VAD) require prior authorization; providers must call the notification number on the member's health plan ID card or the Optum VAD Case Management Team for authorization and case management (examples: CPT 33927-33929, 33975-33983; HCPCS Q0507-Q0509 and related codes).
CPT / HCPCS / ICD-10 Code Lists and Thresholds
Covered CPT codes (selected groups)CPTCovered
31240
FESS, maxillary antrostomy or ethmoidectomy (selected)
31253
Nasal/sinus endoscopy with removal of disease, maxillary sinus; total or complete
31254
...
31255
...
31256
...
31257
...
31259
...
31267
...
31287
Gender-affirming genital surgery code example
31288
...
1–10 of 77
1/8
Diagnosis codes exempt from PA (examples)ICD-10
C50.019
Malignant neoplasm of unspecified site of right female breast (example list)
D05.00
Lobular carcinoma in situ of breast
Diagnosis and device complication groupsmixed
T82.818A
Complication of cardiac electronic device, initial encounter
T82.868A
Other complication of cardiac device, initial encounter
I73.00
Raynaud's syndrome
Procedure and drug code groups (examples)mixedCovered
J0896
Epoetin alfa (anemia) — prior auth required
J1437
Injection code listed in source — prior auth
J1439
Injection code listed in source — prior auth
Ventricular assist device (VAD)HCPCSCovered
L8692
Ventricular assist device — contact Optum VAD Case Management Team
Submission Methods, Contacts, and Actionable Provider Guidance
Prior Authorization
Submission Methods and General Authorization Rules
Prior authorization is required for many elective procedures and select medications. Submit requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In -> Prior Authorization and Notification tab). Chat is available 24/7 via the Contact us page. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services. Facilities must verify coverage approval is on file before performing a service; services performed without required prior authorization may be denied.
Submit online via Prior Authorization and Notification tool on UnitedHealthcare Provider Portal.
The following is a consolidated (partial) list of procedures that require prior authorization. This list is not exhaustive — refer to the Provider Portal for full details and for code-specific requirements.
Definitions and Key Terms
Prior authorization definition
DefinitionPrior authorization: an approval required before elective services are performed; failure to obtain authorization may result in denial of payment.
Emergency/Urgent carePrior authorization is not required for emergency or urgent care.
Provider responsibilityIt is the physician's responsibility to obtain relevant prior authorization; facilities must verify approval is on file before performing the service.
Bariatric surgery coverage
RequirementBariatric surgery and specific obesity-related services require prior authorization for listed CPT/HCPCS codes.
Diagnosis-specificPrior authorization is required for certain diagnosis codes (examples listed in policy: E66.01, E66.09, E66.1–E66.3, E66.8, E66.9, Z68.1, Z68.20–Z68.45).
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyPrior authorization and notification requirements for participating providers
Policy CodePolicy N/A
Change TypeAdministrative review — no material changes
Effective DateSep 1, 2024
Next Review DateN/A
Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or 24/7 chat; obtain authorization before elective services.
Injectable medications across multiple therapeutic categories require prior authorization; submit requests using the Provider Portal Specialty Pharmacy Transactions tile or follow specialty pharmacy vendor submission instructions where indicated. Predetermination is available for non-participating providers and recommended for certain new-to-market drugs.
Therapy (physical, occupational, speech) prior authorization requests cannot be submitted online; fax requests to Clinical Care Coordination at 888-831-5080 using the Rehabilitation Services Extension Request Form; initial referrals valid up to 8 visits per condition within 6 months unless otherwise specified.
Arthroplasty and selected arthroscopy procedures (selected CPT/HCPCS codes listed in plan)
Bariatric surgery (e.g., 43644, 43645, 43659, 43770)
Bone growth stimulators (20974, 20975, 20979)
BRCA genetic testing and related U-codes (e.g., 81162–81164, 81277, 0417U–0475U, S3854, S3865)
Foot surgery and FESS (e.g., 28289–28299; 31240, 31253–31259, 31267)
Hysterectomy and infertility services (selected CPTs such as 58267, 58270, 58541–58550, 58661, 58940, 58974–58976, S4027–S4042)
Home health in-home non‑nutritional services (T1000, T1002, T1003)
Infertility and related diagnostics and treatments (selected CPT/HCPCS codes listed)
MRgFUS and select radiology/radiation therapy (prior authorization required)
Non-emergency air transport (A0430–A0436, S9960) and orthognathic surgery (21050, 21060, 21121–21127, 21141–21145)
Pain management injections and many other specialty surgical and diagnostic procedures (selected CPT/HCPCS codes listed in plan)
Prior Authorization
Site-of-Service Review and Office-Based Program Rules
Site-of-service review applies for many procedures. When indicated in the list, the prior authorization process will include review of the requested place of service — for example, office vs ambulatory surgery center vs outpatient hospital — and prior authorization may be required or denied based on appropriateness of site. Exceptions to site-of-service review are noted for specified states (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin).
Site-of-service review performed for many codes — check code-specific entries.
Prior Authorization Submission and Oncology/Injectable Requirements
Prior authorization submissions for oncology and many injectable therapies must be made online via the Provider Portal. For oncology injectables and supportive care drugs administered in outpatient settings, prior authorization is required for chemotherapy injectable drugs billed J9000–J9999, certain Q-codes, leucovorin/levoleucovorin (J0640–J0642), leuprolide (J1950/J1952), lanreotide (J1932), and agents billed under miscellaneous HCPCS. For oncology and many supportive-care injectables (e.g., colony-stimulating factors, pegfilgrastim products), follow oncology-specific submission pathways on the Provider Portal or call 888-397-8129 for assistance.
Submit oncology and chemotherapy injectable prior authorization online via Prior Authorization and Notification tool.
Injectable chemotherapy drugs requiring prior authorization include J9000–J9999, specified J-codes (J0640–J0642, J1932, J1950/J1952), Q-codes and miscellaneous HCPCS when appropriate.
For oncology supportive agents (colony-stimulating factors, pegfilgrastim, eflapegrastim, filgrastim products), submit online or call 888-397-8129.
For oncology genetic testing and BRCA counseling requirements, see Oncology Prior Authorization resources on the Provider Portal.
Prior Authorization
Cartilage Implant and Select Procedure/Drug Prior Authorization
Certain cartilage implant procedures and related supplies/drugs require prior authorization. This includes cartilage implantation CPT/arthroscopy codes and related HCPCS/J-codes listed.
Related supply/drug codes requiring authorization: J7330, S2112.
Prior Authorization
Inpatient Video EEG Monitoring Prior Authorization Guidance
Inpatient video EEG monitoring (cerebral seizure monitoring — inpatient) requires prior authorization. Outpatient video EEG monitoring is not subject to inpatient authorization requirements.
Inpatient video EEG monitoring CPT codes: 95700, 95711–95713, 95715–95718 (prior authorization required for inpatient services).
Outpatient video EEG monitoring: prior authorization not required for outpatient setting (verify plan specifics).
Prior Authorization
Clinical Trials Prior Authorization
Clinical trial services and procedures billed with clinical trial HCPCS codes require prior authorization. Include study identifiers and supporting documentation when submitting.
Provide clinical trial identifiers and documentation with the prior authorization request.
Prior Authorization
VAD / Congenital Heart Disease Prior Authorization and Case Management Contact
Ventricular assist devices (VAD) and many congenital heart disease procedures require prior authorization and case management coordination. Providers should contact the Optum VAD Case Management Team for authorization and care coordination.
VAD/Congenital heart disease codes listed in the plan require prior authorization (e.g., 33927, 33928, 33929, 33975–33983 and related Q-codes).
For VAD and certain cellular/gene therapy coordination, call Optum VAD Case Management Team at 888-936-7246 or use the notification number on the member's health plan ID card.
Care providers must request prior authorization and coordinate with case management for ventricular assist device placement and related evaluations.
Prior Authorization
Home Health Prior Authorization
Home health in‑home non‑nutritional services require prior authorization. Submit requests with the appropriate visit codes and clinical documentation.
Prior authorization required for in-home nursing services and home health non-nutritional codes: T1000, T1002, T1003.
Include clinical justification and plan of care when submitting prior authorization for home health services.
Prior Authorization
Injectable Medications: Prior Authorization and Submission Process
Many injectable medications require prior authorization. Submission routes depend on drug class and whether the medication is managed through specialty pharmacy or oncology pathways. Providers should use the Provider Portal Specialty Pharmacy Transactions tile for specialty drugs and the Prior Authorization and Notification tool for most injectable authorizations. For enzyme replacement therapies, many are authorized for POS 19 and 22 only and may require submission to the specialty pharmacy vendor with the medication order.
Submit injectable medication prior authorization requests via the Provider Portal; use the Specialty Pharmacy Transactions tile when indicated.
Examples of injectable drug categories requiring prior authorization: colony-stimulating factors (J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125), denosumab (J0897), epoetin (J0885), enzyme replacement therapies (select J-codes), and many specialty biologics (numerous J-codes listed in plan).
For some drugs (e.g., certain enzyme replacement therapies), authorization must be submitted to the specialty pharmacy vendor with the medication order.
If prior authorization requirements are not met, UnitedHealthcare will contact the provider's office within 3 days; authorized pharmacy services will send authorization letters with numbers and coverage dates.
Prior Authorization
Out-of-Network Referral Prior Authorization
Out-of-network referrals from a network provider require prior authorization when a network physician or other health care professional directs a member to an out-of-network facility, physician or other health care professional and the member's plan includes out-of-network benefits. Verify plan-specific out-of-network benefit details and notify the member regarding potential increased out-of-pocket costs.
Prior authorization is required when a network provider directs a member to an out-of-network provider or facility (if the member's plan allows out-of-network benefits).
Check the member's benefit plan for out-of-network coverage limitations and obtain prior authorization before arranging services.
Prior Authorization
Sinuplasty Prior Authorization
Sinuplasty procedures require prior authorization. Submit the appropriate CPT codes and supporting clinical documentation.
Sinuplasty CPT codes that require prior authorization: 31295, 31296, 31297.
Prior Authorization
Spinal Cord Stimulator Prior Authorization and Site-of-Service Review
Spinal cord stimulator (SCS) implantation and related neurostimulator services require prior authorization for all states. Site-of-service review will apply for select SCS codes (exceptions may apply for specified states). Include prior conservative therapy documentation and trial/staged procedures as requested.
SCS CPT codes requiring prior authorization include 63650, 63655, 63662, 63664, 63661 (and related implantation/revision codes such as 63685, 63688, 64553, 64570).
Supply/prosthetic codes (L8679–L8688, L8685–L8688, etc.) require authorization where listed.
Spinal surgery procedures require prior authorization in all states. Many specific spinal CPT codes are subject to site-of-service review during authorization.
Extensive list of spinal surgery CPT codes requiring prior authorization is provided in the plan (examples include 20930, 20931, 22100–22116, 22206–22226, 22510–22515, 22532–22554, 22600–22633, 22800–22861, 27279–27280 and many others).
Site-of-service review will be part of the prior authorization process for listed spinal codes (exceptions for AK, MA, PR, RI, TX, UT, VI, WI).
Site-of-service (office-based program) rules: certain procedures performed in an outpatient hospital or ambulatory surgery center will require prior authorization when listed. If performed in a network ambulatory surgery center (ASC) some services may not require outpatient hospital prior authorization — check the code-specific guidance.
Office-based procedures that are performed in an outpatient hospital setting or ASC may trigger prior authorization and site-of-service review (selected CPTs such as 11402–11406, 11420–11426 and many others listed).
Prior authorization not required for some procedures when performed at a network ASC — verify per-code guidance and state exceptions.
Cellular and gene therapy services (including CAR-T and other labeled cellular/gene therapies) require prior authorization or notification and centralized coordination. For examples of covered/managed therapies and to request authorization or case management, contact the Optum notification line.
For prior authorization or case management for cellular & gene therapies call 888-936-7246 or the notification number on the member's health plan ID card.
Providers must request prior authorization before pre-treatment evaluation or treatment for transplant, cellular and gene therapy services.
Coverage limitationSome benefit plans may not cover bariatric or obesity-related services in certain situations; verify member benefits and plan rules.
BRCA genetic testing requirements
RequirementBRCA and many genetic tests require prior authorization before DNA sequencing-based testing is performed.
Pre-test counselingGenetic counseling is required prior to testing for many hereditary genetic tests and an attestation form may be required.
Example CPT codesExamples of BRCA-related CPT codes listed: 81162, 81163, 81164, 81277, 81349 and multiple genomic sequencing U-codes (e.g., 0288U, 0029U).
Cancer supportive care
Included servicesSupportive cancer care including outpatient injectable chemotherapy, colony-stimulating factors, anti-emetics and bone-modifying agents require prior authorization when used for a cancer diagnosis.
ExamplesExamples include colony-stimulating factors (e.g., J1449, J1442, Q5110, Q5101, J2506) and anti-emetics listed in the policy (e.g., J1454, J0185, J1453).
SubmissionPrior authorization requests for these agents should be submitted via the Provider Portal PA and Notification tool or by calling the number provided (888-397-8129) as noted in the policy.
Prior authorization submission
Primary submission methodSubmit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).
Alternate methodConnect via 24/7 chat using the Contact us page; certain services also list a phone number (e.g., 888-397-8129) for submission guidance.
Service-specific routesSome service types (e.g., therapy referrals) require fax submission to Clinical Care Coordination as specified in the policy.
Clinical trials
DefinitionClinical trial: a rigorously controlled study of a new drug, medical device or other treatment on eligible human subjects.
Team roleOptum VAD Case Management Team is the contact resource for ventricular assist device (VAD) and congenital heart disease prior authorization and case management.
When to contactProviders should contact this team for prior authorization/notification related to VAD-related items coded L8692 and associated procedures.
Optum VAD Case Management Team phone
Phone number888-936-7246 (Optum VAD Case Management Team) — contact for VAD, congenital heart disease and certain cellular/gene therapy notifications.
Alternate instructionProviders may also use the notification number on the member's health plan ID card as directed in the policy.
Continuous glucose monitor (CGM)
RequirementContinuous glucose monitor (CGM) HCPCS codes listed (e.g., A4226, A4238, A4239, A9276–A9278, E0787, E2102, E2103) require prior authorization when used for type 2 diabetes.
ActionProviders must obtain prior authorization for CGM use in type 2 diabetes as indicated in the policy before dispensing or billing.
Cosmetic and reconstructive procedures
RequirementCosmetic and reconstructive procedures listed in the policy require prior authorization in all states for the enumerated CPT codes.
Site-of-service reviewSite-of-service will be reviewed as part of the prior authorization process for many codes, with exceptions for specified jurisdictions (AK, MA, PR, RI, TX, UT, VI, WI).
ExamplesRepresentative CPT examples include 11960, 11970, 14020*, 15773 and numerous other reconstructive/cosmetic CPTs listed in the policy.
DME
DefinitionDurable Medical Equipment (DME): items listed in the DME section subject to prior authorization rules; PA required only when retail purchase or cumulative rental cost exceeds $1,000 for listed DME codes.
Relation to prostheticsProsthetics are not treated as DME for the DME $1,000 threshold; prosthetics have a separate prior authorization rule tied to purchase/rental cost.
ActionVerify specific HCPCS codes against the DME list to determine if PA is required based on cost threshold or device-specific rules.
site-of-service
DefinitionSite-of-service review: the payer reviews whether a service performed in an outpatient hospital or ASC/office setting requires prior authorization based on where the service is provided.
ImplicationSome services may not require prior authorization when performed in-office or at a network ASC but will require PA if performed in an outpatient hospital setting.
Injectable medications
DefinitionInjectable medications: drugs administered intravenously (including infusion), subcutaneously or intramuscularly; many listed injectable J-codes require prior authorization.
Special handlingSome injectable therapies (e.g., enzyme replacement therapies) may be restricted to specific places of service (POS 19 & 22) and require submission to a specialty pharmacy vendor as noted.
Submission guidanceProvider Portal and Specialty Pharmacy Transactions tile are referenced for submission of specialty injectables; predetermination recommended for new-to-market drugs.
Enzyme replacement therapy (POS restriction)
POS restrictionEnzyme replacement therapies: authorizations may be restricted to place of service (POS) 19 and 22 only and must be submitted to the specialty pharmacy vendor with the medication order.
ExamplesPolicy notes enzyme replacement therapy entries and indicates submission routing to specialty pharmacy and POS limits.
MRgFUS
DefinitionMRgFUS: MR-guided focused ultrasound procedures (e.g., CPT 0071T, 0072T) to treat uterine fibroid require prior authorization and member/facility safeguards.
PreconditionsPhysician/facility must confirm coverage, facility must be contracted, member must provide written consent acknowledging limited evidence and agree not to hold payer responsible for unsatisfactory results.
ExamplesMRgFUS procedure codes listed include 0071T and 0072T; related drug/procedure codes and new-to-market guidance also provided.
Post-acute inpatient services
DefinitionPost-acute inpatient services include acute care hospitals, inpatient rehabilitation, critical access hospitals, long-term acute care hospitals and skilled nursing facilities; prior authorization and admission-date notification are required for these facilities.
ActionProviders must request prior authorization and notify the payer of the admission date for post-acute inpatient services as specified.
Out-of-network services (directed referrals)
When requiredPrior authorization is required when a network provider directs a member to an out-of-network facility/provider and the member's plan allows out-of-network benefits.
Member impactMembers may have increased out-of-pocket expenses or no coverage when using out-of-network providers; verify plan benefits.
Out-of-network services
TermOut-of-network services: services provided by non-participating providers—prior authorization rules apply when referred by a network provider and plan includes out-of-network benefits.
VerificationProviders should verify member benefits and follow PA procedures when directing members to out-of-network care.
Potentially unproven/experimental services
DefinitionPotentially unproven/experimental services: services determined to have insufficient clinical evidence from well-conducted randomized controlled trials or cohort studies; these services require prior authorization.
Evidence basisDeterminations are based on the prevailing published, peer-reviewed medical literature and the absence of sufficient high-quality evidence.
Site of service (SOS) - office-based program / outpatient hospital
DefinitionSite of service (SOS) rules: whether prior authorization is required can depend on where a service is performed (office vs outpatient hospital or ambulatory surgery center); services performed in outpatient hospitals often trigger PA review.
Office-based exceptionSome codes do not require prior authorization when performed in-office or at a network ASC, but do require PA when performed in an outpatient hospital setting.
Prior authorization required
Provider obligationPrior authorization is a provider obligation: care providers must request and obtain approval from the payer before performing listed elective services to ensure coverage.
ConsequencesServices performed without required prior authorization may be denied payment; final coverage decisions are based on plan, eligibility and applicable law.
Prior authorization
LabelPrior authorization — requirement to obtain approval before elective services are performed.
NoteEmergency and urgent care are exempt from prior authorization requirements.
Cellular & Gene Therapy
DefinitionCellular & gene therapy: advanced biologic therapies (examples listed include Kymriah, Yescarta, Tecartus and others) that require notification or prior authorization.
ActionProviders must obtain prior authorization/notification for listed cellular and gene therapies and may be instructed to call the provided contact number (888-936-7246) or use the member ID notification number.
ExamplesNamed products in the policy include Amtagvi, Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, Tecartus, Lenmeldy, Skysona, Zynteglo and others.
Vein procedures (saphenous/veins of extremities)
DefinitionVein procedures: removal and ablation of the main trunks and named branches of the saphenous veins and treatment of veins of the extremities for venous disease and varicose veins; these procedures require prior authorization.
MappingPolicy maps vein-related HCPCS (A95xx, A96xx series) to CPT codes such as 36470–36479, 37243, 37700, 37718, 37722 and others.
Ventricular assist devices (VAD)
DefinitionVentricular assist device (VAD): a mechanical pump supporting the damaged ventricle; VAD-related services and devices require prior authorization.
Contact/actionFor VAD items (e.g., HCPCS L8692 and related CPTs 33927–33983/Q0507–Q0509), providers should call the notification number on the member's health plan ID card or contact the Optum VAD Case Management Team (888-936-7246) to obtain prior authorization/notification.
ExamplesRepresentative VAD procedure CPTs listed include 33927, 33928, 33929, 33975–33983 and related Q-codes.