CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for New York Medicaid

Defines prior authorization (PA) requirements and submission methods for participating providers delivering inpatient and outpatient services to New York Medicaid members covered by Colorado Rocky Mountain Health Plans (UnitedHealthcare Community Plan of New York). Applies to participating health care professionals and specifies services and codes that require PA.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 866-362-3368.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

July 1, 2024effective date

Online portalprimary submission method

866-362-3368general PA phone number

Elective inpatientrequire prior authorization

$500

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.

200+codes referenced

Prior Authorization Coverage Criteria

General PA coverage stance and service-level requirements

General coverage stance and service-specific prior authorization (PA) requirements:

All planned, elective inpatient services require prior authorization.

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

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

Submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) using One Healthcare ID; phone option: call 866-362-3368.

Service-level examples

Cardiology: outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants, and stress echoes require prior authorization before performance.
Cancer supportive care: colony‑stimulating factors and bone‑modifying agents administered in the outpatient setting for a cancer diagnosis require prior authorization.

Providers should use the portal first; phone contacts are provided for select specialty areas as noted in the policy.

Partial coverage and prior authorization notes

Coverage notes and service-specific PA exceptions / thresholds:

Cerebral seizure monitoring: prior authorization is required for inpatient services; inpatient video EEG prior authorization is not required for outpatient hospital or ambulatory settings (specific CPTs listed).

Chemotherapy injectable drugs and related Q‑coded or miscellaneous HCPCS billed injectables require prior authorization; submit requests online via the Provider Portal.

Cochlear and other auditory implants require prior authorization (specific CPT/HCPCS codes listed).

Durable medical equipment (DME): prior authorization is required only for listed DME codes when retail purchase or cumulative rental cost exceeds the referenced threshold (see $500 threshold). Some prosthetics are not considered DME.

The policy enumerates many injectable medications (by J/Q codes) that require prior authorization; see the injectable medications and Launch Medication List sections for details.

Prior authorization coverage criteria (excerpt)

Covered when prior authorization or notification is obtained as specified below:

Experimental and investigational services (and linked codes) require prior authorization.

Functional endoscopic sinus surgery (FESS) and femoroacetabular impingement (FAI) arthroscopy procedures require prior authorization (CPT lists provided).

Genetic and molecular testing (including BRCA) require prior authorization/notification; notification is required before DNA sequencing is performed and the ordering clinician must notify the laboratory.

Gender dysphoria surgical procedures require prior authorization with diagnosis crosswalks and related surgical code groupings provided.

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

Prior authorization requirements (partial extract)

Prior authorization requirements for procedures and injectable medications (partial extract):

Hysterectomy CPT codes (e.g., 58150, 58152, 58180, 58260, 58262, etc.) are listed as prior authorization required.

Injectable medications: numerous biologic and specialty drugs (listed by name and J/Q codes in the document) require prior authorization.

Examples of injectable drugs listed

Actemra (J3262), Acthar (J0800), Adakveo, Cimerli (Q5128), Cimzia (J0717), Eylea HD (J0177) and many others are included in the injectable medications list requiring PA.
Refer to the Launch Medication List and injectable medication sections for full code mappings and PA instructions.

For certain unclassified/temporary HCPCS codes, prior authorization is required only for specified products named in the policy (see Launch Medication List).

Partial coverage mapping and notes

Mappings and special notes for high-cost/new-to-market medications:

Zolgensma is referenced with HCPCS/J codes J9202 and J3399; repeated notes instruct providers to check the 'Medications newly approved' / Launch Medication List for authorization guidance.

Several high‑cost biologic medications are mapped to HCPCS codes in the list (examples appear throughout the Launch Medication List and injectable medication sections).

J3399 is used in this document as an unclassified placeholder for Zolgensma; for newly approved medications review the Launch Medication List and follow the pre-determination guidance.

Prior authorization criteria (partial)

PA criteria and submission instructions for Launch Medication List, procedures and devices (partial):

Launch Medication List: Pre-determination is highly recommended for drugs on the Launch Medication List; certain unclassified/temporary codes require PA only for named products (document lists examples).

Colony-stimulating factors: Codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120 and Q5122 (white blood cell colony‑stimulating factors) require prior authorization for both oncology and non‑oncology diagnoses; oncology DX handled via cancer supportive care section; non‑oncology submissions via UHCprovider.com or phone 877‑842‑3210.

Procedures and devices: Joint replacement, orthognathic surgery, orthotics/prosthetics, non‑emergent air transport and many procedural/device CPT/HCPCS/L‑codes listed on the Launch Medication List are marked prior authorization required.

Submission methods: Submit prior authorization requests online via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by calling the phone numbers listed (e.g., 888‑397‑8129 for general submissions; Cimzia prior notification via Magellan at 800‑788‑4005).

Prior Authorization Criteria by Service and Code

Prior authorization requirements by service category and code examples:

Orthotics and prosthetics: listed L‑codes (examples L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, etc.) require prior authorization; items with retail purchase or cumulative rental cost > $500 are subject to PA rules.

Outpatient therapy services (e.g., 97530, 92507, 97542, S9152) require prior authorization.

Private duty nursing codes (T1000, T1002, T1003) require prior authorization.

Proton beam therapy CPTs (77520, 77522, 77523, 77525) require prior authorization.

Certain advanced outpatient imaging (T‑codes 0712T, 0698T, 0713T, 0710T, 0711T) require prior authorization.

Prior authorization rules (excerpt)

Prior authorization rules and site‑of‑service conditions (excerpt):

Sinuplasty CPT codes 31295, 31296, 31297 require prior authorization.

Site‑of‑service rule: prior authorization is required only when the service is requested in an outpatient hospital; PA is not required if performed at a participating ASC.

Sleep studies (CPTs 95805, 95811, 95807, 95808, 95810) require prior authorization; an exception applies — PA is not required for New York long‑term services and supports (LTSS).

Prior authorization coverage stance by category

Coverage stance and PA requirements by service category:

Stimulators and implantable electrical devices (neurostimulators, bone growth stimulators) require prior authorization (device and associated HCPCS/CPT codes listed).

Transplants and CAR‑T cell therapies require prior authorization and case management contact; providers are instructed to contact the UnitedHealthcare Community and State Transplant Case Management team for these services.

Vein procedures (including removal/ablation of saphenous trunks and branches) require prior authorization; associated CPT/HCPCS and drug code placeholders are listed in the policy.

Ventricular assist devices (VAD) require prior authorization; providers must call the notification number on the member ID card and fax forms to the Optum VAD Case Management team (855‑282‑8929).

Wound vacuum (wound vac) therapy requires prior authorization (E2402 and related HCPCS/J‑code placeholders referenced).

CPT / HCPCS / ICD-10 and Code Lists

Covered CPT codes - Cardiology & Endovascular (selected)CPTCovered

37220	Transcatheter placement of intravascular stent(s), percutaneous, initial vessel
37221	Transcatheter placement of intravascular stent(s), percutaneous, each additional vessel
37224	Transcatheter placement of intravascular stent(s), open or percutaneous, for peripheral vessel
37225	Transcatheter placement of intravascular stent(s), each additional peripheral vessel
37226	Transcatheter placement of intravascular stent(s) — related code grouping
37227	Transcatheter stent placement — related code grouping
37228	Transcatheter stent placement — related code grouping
37229	Transcatheter stent placement — related code grouping
37230	Transcatheter placement of intravascular stent(s), additional mapping
37231	Transcatheter placement of intravascular stent(s), additional mapping

Covered HCPCS / J / Unclassified codes (sample listed)HCPCSCovered

C9090	Unclassified drug code - prior authorization may apply
C9149	Unclassified drug code - prior authorization may apply
C9151	Unclassified drug code - prior authorization may apply
C9166	Unclassified drug code - prior authorization may apply
C9167	Unclassified drug code - prior authorization may apply
C9168	Unclassified drug code - prior authorization may apply
C9399	Unclassified HCPCS code - see policy for specific agents
J3490	Unclassified drug, single source — see policy for agents requiring PA
J3590	Unclassified drug, multiple source — see policy for agents requiring PA

Covered CPT spine / orthopedic surgical ranges (selected mappings)CPTCovered

22551	Anterior cervical discectomy and fusion (example in range)
22554	Additional cervical fusion code (range)
22600	Arthrodesis, posterior or posterolateral technique — range start
22610	Arthrodesis lateral fusion (range)
22800	Application of halo or traction apparatus — range examples
22808	Placement of instrumentation (spine) — range examples
22810	Insertion of instrumentation (spine) — range examples
22819	Removal or revision of instrumentation — range examples
22830	Arthrodesis, anterior column support — range examples
22849	Insertion of interbody device — range examples

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Referenced Diagnosis codes (examples supporting PA for 3722x series)ICD-10

E08.52	Diabetes mellitus due to underlying condition with peripheral angiopathy
E09.52	Drug or chemical induced diabetes with peripheral angiopathy
E10.52	Type 1 diabetes with peripheral angiopathy
E11.52	Type 2 diabetes with peripheral angiopathy
E13.52	Other specified diabetes with peripheral angiopathy
I70.221	Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222	Atherosclerosis of native arteries of extremities with rest pain, left leg
I70.223	Atherosclerosis of native arteries of extremities with rest pain, bilateral
I70.228	Atherosclerosis of other specified arteries of extremities
I70.229	Atherosclerosis of unspecified arteries of extremities

Genetic / Molecular testing codes requiring PACPTCovered

81162	BRCA1/BRCA2 (comprehensive)
81163	BRCA large rearrangement testing
81164	BRCA family variant testing
81228	BRCA, full sequence
81229	BRCA targeted variant
81400	Molecular pathology procedures — tier 1
81401	Molecular pathology procedures — tier 2
81402	Molecular pathology procedures — tier 3

Selected CPT/HCPCS codes requiring prior authorization (examples consolidated)mixedCovered

31295	Balloon sinuplasty — prior authorization required
31296	Balloon sinuplasty — prior authorization required
31297	Balloon sinuplasty — prior authorization required
64721	Carpal tunnel surgery — selected procedure
36590	Insertion of temporary venous catheter — cardiovascular
36832	Thrombectomy — selected
66821	Cataract surgery — typical mapping to 66982/66984
45378	Colonoscopy — selected mappings
29805	Shoulder arthroscopy — selected
29826	Arthroscopy with repair — selected

Sample injectable medication HCPCS/J-codes (selected list)HCPCSCovered

J0597	Berinert
J0585	Botulinum toxins
J0567	Brineura
J1786	Cerezyme
Q5128	Cimerli
J0717	Cimzia
J2786	Cinqair
J0598	Cinryze
J1551	Cutaquig
J0589	Daxxify

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How Providers Must Submit and What to Do

Prior Authorization

Prior Authorization Submission — General rule

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com — Sign In with One Healthcare ID, then select Prior Authorization and Notification). Phone contact numbers for specific programs/services are listed below; follow the listed process for medications, high-cost biologics, transplants/CAR T, VADs and other case-managed services. Note: All planned elective inpatient services require prior authorization. Prior authorization is not required for emergent/urgent care. Prior authorization is required for non-emergent out-of-network services regardless of place of service.

Online: UHCprovider.com > Sign In > Prior Authorization and Notification tab
General phone (when specified in sections below) — see individual entries

Prior Authorization

Cancer Supportive Care Medications — Prior Authorization Required

Cancer supportive care colony-stimulating factors and bone-modifying agents administered in the outpatient setting for a cancer diagnosis require prior authorization. For oncology and non-oncology diagnoses certain single-source/brand biologics and colony-stimulating factors (see injectable medications/high-cost medications blocks) require PA. Submit requests online via the Prior Authorization and Notification tool at UHCprovider.com or call 888-397-8129.

Terminology and Scope Definitions

inv-78: Prior authorization (definition and scope)

DefinitionPrior authorization (PA) is the process by which planned, elective inpatient services and certain outpatient services must be approved by the health plan before performance.

When requiredAll planned, elective inpatient service requests require prior authorization; non‑emergent out‑of‑network services also require PA regardless of place of service.

When not requiredPA is not required for emergent or urgent care or for services performed at participating ASCs when the site‑of‑service rule exempts them.

How to submitSubmit requests online via the Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID) or by calling the designated PA phone numbers.

inv-79: Cancer supportive care definition

Definition

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests using the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or call 866-362-3368.

SourceLink

On This Page

Hysterectomy procedure codes require prior authorization (specific CPT codes listed).

Shoulder surgery CPTs (29805–29828 series listed) require prior authorization.

Site‑of‑service rule: Prior authorization is required only when requesting the service in an outpatient hospital setting; PA is not required if performed at a participating ambulatory surgical center (ASC).

Drugs that require PA for oncology outpatient use include: Filgrastim/pegfilgrastim products and Q-codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 (PA also required for non-oncology DX)
Anti-emetics requiring PA include: J1454 (Akynzeo), J0185 (Cinvanti), J1453 (Emend/fosaprepitant), J1627 (Sustol)
Bone-modifying agent requiring PA: Denosumab (Xgeva)

Prior Authorization

Cardiology Prior Authorization — Outpatient/Office-based

Cardiology procedures performed in outpatient and office settings require prior authorization before performance. This includes outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants, and stress echocardiography. For cardiology PA submit online via the Provider Portal or call the dedicated Cardiology PA number.

Cardiology PA phone: 866-889-8054
Example CPT referenced in guidance: 93319 — see Cardiology Prior Authorization and Notification for full CPT list

Prior Authorization

Cerebral Seizure Monitoring / Inpatient Video EEG — Prior Authorization

Cerebral seizure monitoring and inpatient video EEG require prior authorization for inpatient services. Outpatient/ambulatory video EEG does not require PA. Submit PA requests online via the Provider Portal.

CPT codes that commonly require PA for inpatient seizure monitoring: 95700, 95711, 95712, 95713
Inpatient video EEG CPTs: 95714, 95715, 95716, 95718
Prior authorization required only for inpatient settings; outpatient hospital/ambulatory video EEGs do not require PA

Prior Authorization

Prior Authorization Required — Selected V52xx and Related Codes

Selected V52xx (prosthetic/orthotic related V-codes) and related supply codes require prior authorization. Check member ID card notification number or submit via the Provider Portal for DME/orthotics/prosthetics that meet PA thresholds (retail purchase or cumulative rental > $500 or codes specifically listed).

Selected V52xx/V52‑related codes listed in the provider file require PA (examples in source: V5269, V5270, V5271, V5272, V5274, V5281–V5283, V5286–V5290)
DME/Orthotics with retail purchase or cumulative rental cost > $500 require PA; specific HCPCS/L-codes listed in the orthotics & prosthetics section require PA

Prior Authorization

FAI Procedure Codes — Prior Authorization

Femoroacetabular impingement (FAI) and related hip preservation procedures (including arthroscopic procedures often used for FAI) require prior authorization when listed codes are billed in an outpatient hospital setting. Verify PA via the Provider Portal before scheduling.

Many joint/hip procedure CPTs require PA when performed in outpatient hospital site-of-service — check joint replacement and musculoskeletal PA rules
If performed in a participating ambulatory surgical center (ASC), site-of-service PA rules may differ (see Site of Service block)

Prior Authorization

Hysterectomy Codes — Prior Authorization Required

Hysterectomy procedures require prior authorization. Submit PA for the specific hysterectomy CPT code prior to the procedure.

Example CPTs requiring PA include: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58290, 58291, 58292, 58541–58554, 58570–58573
Ensure appropriate diagnostic coding and clinical documentation accompany PA request

Prior Authorization

Injectable Medications — Prior Authorization

Injectable medications, including many J-/Q-codes and other HCPCS-injectable drugs, require prior authorization. This includes oncology chemotherapy injectables, colony-stimulating factors, many biologics, and high-cost specialty injectables. Use the Provider Portal for PA submission or the phone numbers listed for oncology/supportive care.

Chemotherapy injectables (J9000–J9999) and miscellaneous HCPCS (including Q-codes and unclassified codes billed under J3490/J9999) require PA
Examples of injectable drugs requiring PA or special handling: Leucovorin J0640, Levoleucovorin J0641/J0642, Lupron Depot J1950, colony-stimulating factors (J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122), Actemra J3262, Acthar J0800, Adakveo, Xembify J1558, Xenpozyme J0218, Zemaira J0256, Zoladex J9202, Zolgensma J3399
Unclassified/temporary codes (C9090, C9149, C9151, etc.) and J3490/J3590 may require PA for specific recently approved high-cost drugs

Prior Authorization

Additional Listed Codes — Prior Authorization

Additional listed codes include DME/orthotics/prosthetics HCPCS and L-codes, enteral nutrition product codes, wound care supplies, and other service codes that require prior authorization when listed. Follow the Provider Portal process and include cost/receipt details for DME where purchase/rental thresholds apply.

Enteral services codes (examples): B4102, B4103, B4104, B4150, B4152, B4153, B4158, B4159, B4160, B9002, B9998
DME/HCPCS examples requiring PA when thresholds met: A4575, A9279, A9280, A9900, E-series codes (E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471, E0483, E0486)
Wound vac E2402 and other equipment may require PA

Prior Authorization

High-cost / Biologic Medication Codes — Prior Authorization

High-cost and biologic medications require prior authorization and often pre-determination. Many are mapped to specific J- or Q-codes and unclassified codes; check the Launch Medication List and submit PA via the Provider Portal or designated specialty phone lines. Some products require notification through external vendors (eg, Magellan) per the Launch Medication List notes.

Examples of mapped high-cost drugs: Xembify (J1558), Xenpozyme (J0218), Zemaira (J0256), Zoladex (J9202), Zolgensma (J3399), Vyvgart (J9332/J9334)
White blood cell colony-stimulating factors (J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require PA for oncology and non-oncology diagnoses
Pre-determination recommended for drugs on the Launch Medication List; Cimzia prior notification via Magellan: 800-788-4005

Prior Authorization

Procedures and Device Codes — Prior Authorization Required

Procedures and device services across multiple specialties require prior authorization. This includes joint replacements, many musculoskeletal surgeries, non-emergent air transport, orthognathic surgery, selected ENT/OSA procedures, sleep studies (with LTSS exception), spinal surgery, sinoplasty/FESS, and other surgical/device implantations. Confirm PA requirements and site-of-service rules before scheduling.

Joint replacement (total hip/knee) and many musculoskeletal CPTs require PA (see joint replacement list)
Non-emergent air transport codes A0430–A0436 require PA
Orthognathic surgery and maxillofacial functional impairment procedures require PA
Advanced outpatient imaging (certain CT/MRI/MRA/PET and specific T-codes) require PA

Prior Authorization

Orthotics and Prosthetics — Prior Authorization

Orthotics and prosthetics listed with retail purchase or cumulative rental cost thresholds require prior authorization. Specific L-codes and L-series items are subject to PA; include cost details and clinical justification when submitting.

Selected L‑codes requiring PA include: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631–L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L7181, L7185, L7186, L7190, L7191, L7405, L8040–L8047, L8499, L8609, L8610, L8612, L8631, L8659
Prosthetics are not always treated as DME — verify code-specific rules

Prior Authorization

Outpatient Therapy — Prior Authorization

Outpatient therapy services require prior authorization for many therapy CPTs. Submit PA requests with clinical justification and expected treatment goals.

Example codes requiring PA: 97530 (therapeutic activities), 92507 (speech/hearing services), 97542 (wheelchair management), S9152 (home-based therapy)
Outpatient therapy PA is required prior to initiation of services

Prior Authorization

Private Duty Nursing — Prior Authorization

Private duty nursing services require prior authorization. Submit clinical justification and anticipated hours of care when requesting PA.

Typical CPT/HCPCS codes: T1000, T1002, T1003
PA required before initiation of private duty nursing services

Prior Authorization

Proton Beam Therapy — Prior Authorization

Proton beam therapy requires prior authorization. Submit PA for proton therapy planning and delivery CPTs prior to scheduling.

Proton beam therapy CPTs include: 77520, 77522, 77523, 77525 (PA required)
Advanced radiation modalities require PA and clinical justification

Prior Authorization

Nasal Functional Impairment / Septal Deviation & Sinuplasty / FESS — Prior Authorization

Treatment of nasal functional impairment and septal deviation (including septoplasty/functional rhinoplasty) requires prior authorization for listed CPT codes. Sinuplasty and FESS procedures also require PA.

Nasal/septal CPTs requiring PA include: 30435, 30450, 30460, 30462, 30465
Sinuplasty CPTs requiring PA: 31295, 31296, 31297
Functional endoscopic sinus surgery (FESS) CPTs requiring PA: 31240, 31253–31257, 31259, 31267, 31276, 31287, 31288

Prior Authorization

Shoulder Surgery — Prior Authorization

Shoulder surgery (arthroscopic and open shoulder procedures) requires prior authorization for many shoulder CPTs. Submit PA with imaging and prior conservative management documentation where applicable.

Shoulder CPTs commonly requiring PA: 29805, 29806, 29807, 29819–29828 (rotator cuff, instability, labral repair and related arthroscopic codes)
Include clinical notes, prior conservative treatment, and imaging with the PA request

Prior Authorization

Stimulators / Implantable Devices — Prior Authorization and Notification

Implantable stimulators and other implantable devices (neurostimulators, bone growth stimulators, VADs, wound VAC systems) require prior authorization and, for select devices, additional case management/notification steps. Follow device-specific PA submission instructions and call the case management contact when directed.

Bone growth and neurostimulators (examples: E0747–E0760 range) require PA
Ventricular assist devices (VADs) require PA and notification: call the notification number on the back of the member's ID card and fax the VAD form to Optum VAD Case Management at 855-282-8929
Wound VAC (example E2402) requires PA

Prior Authorization

Transplants and CAR T‑cell Therapy — Prior Authorization and Case Management Contact

Transplant procedures and CAR T‑cell therapies require prior authorization and case management. Contact the UnitedHealthcare Community & State Transplant Case Management team for all transplant and CAR T requests (including listed CAR T products) prior to scheduling.

For transplant and CAR T services (examples of CAR T products: Abecma, Breyanzi, Carvykti, Kymriah, Lyfgenia, Tecartus, Yescarta, Zynteglo) call the UnitedHealthcare Community & State Transplant Case Management team — use the transplant/case management contact on the member's plan materials or Provider Portal
CPT/HCPCS and procedure codes for transplants (examples include 32850–32856, 33930–33944, 38208–38215, 38232*, 38240–38242, 44132–44137, 50300–50370, 50547) require PA
*Code 38232 requires PA only for oncology diagnoses; many CAR T and unclassified codes require prior authorization/notification

Cancer supportive care includes medications and agents such as colony‑stimulating factors and bone‑modifying agents administered in the outpatient setting for a cancer diagnosis that require prior authorization.

ExamplesColony‑stimulating factors: filgrastim (J1442), pegfilgrastim (J2506) and biosimilars/Q‑codes (Q5101, Q5108, Q5110, Q5111, Q5120, Q5122); bone‑modifying agent: denosumab (Xgeva).

Non‑oncology useCertain colony‑stimulating factor codes (J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) also require PA for non‑oncology diagnoses.

SubmissionSubmit cancer supportive care PA requests online via the Prior Authorization and Notification tool or call the cancer supportive care PA contact (888‑397‑8129).

inv-80: Prosthetics vs DME — prosthetics not considered DME in this segment

Key statementProsthetics are not considered DME for purposes of prior authorization in this segment.

ImplicationOrthotics and prosthetics are listed separately (L‑codes) and have their own PA rules, including purchase‑price thresholds; they are not processed under the DME cost threshold rule.

ExamplesDocument shows DME codes (A‑ and E‑series) subject to the $500 DME threshold, while prosthetics/orthotics use L‑codes (e.g., L0112, L0170, L0456) with separate PA criteria.

inv-81: BRCA testing prior authorization/notification

RequirementNotification or prior authorization is required for BRCA and other specified genetic/molecular testing before DNA sequencing is performed.

Ordering clinician responsibilityThe ordering health care professional must notify the laboratory prior to DNA sequencing for BRCA testing.

Codes referencedBRCA and molecular testing codes listed include 81162, 81163, 81164, 81228, 81229 and multiple 814xx/000xU codes (e.g., 81400–81408, 0006M, 0007M, 0018U, etc.).

inv-82: Home health prior authorization scope

ScopePrior authorization is required for home health care services only when provided in an outpatient setting, which includes the member's home.

CodesHome health care codes listed include G0156, G0162, G0299, G0300 and related G‑series codes that require PA in outpatient settings.

NoteThis PA requirement applies to home health visits billed in outpatient context; inpatient/home‑institutional billing situations follow standard inpatient rules.

inv-83: Injectable medications (definition reference)

DefinitionInjectable medications — products administered by injection that are listed in the policy and require prior authorization; many are identified by HCPCS/J‑codes.

ExamplesIncludes chemotherapy injectables (J9000‑J9999, J0640–J0642, J1950), biologics (J0597, J0567, J1786, Q5128), colony‑stimulating factors (J1442, J2506, Q51xx), and multiple other J/Q codes enumerated in the injectable medications section.

SubmissionSubmit PA requests for injectable medications online via the Prior Authorization and Notification tool or by the phone numbers provided in the Launch Medication List instructions.

inv-84: Hysterectomy (definition reference)

DefinitionHysterectomy — the hysterectomy procedure codes listed in the policy require prior authorization.

CodesHysterectomy CPT codes listed include 58150, 58152, 58180, 58260, 58262 and related CPTs (document enumerates multiple hysterectomy codes requiring PA).

ActionObtain prior authorization prior to scheduling/procedure for listed hysterectomy CPTs via the Provider Portal or designated phone numbers.

inv-85: white blood cell colony-stimulating factors

DefinitionWhite blood cell colony‑stimulating factors are supportive oncology agents listed in the policy that require prior authorization for oncology and non‑oncology indications as specified.

Codes/examplesDocument lists J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122 and others as colony‑stimulating factor codes requiring PA.

Oncology vs non‑oncologyFor oncology diagnoses see the cancer supportive care section; for non‑oncology diagnoses submit PA via UHCprovider.com or call 877‑842‑3210 as directed in the Launch Medication List guidance.

inv-86: J3399 as placeholder

Usage in documentJ3399 is used repeatedly as an unclassified/placeholder HCPCS code associated with Zolgensma and other newly approved medications; the policy directs reviewing the 'Review at Launch/Medications newly approved' guidance.

ImplicationJ3399 entries indicate drugs billed under an unclassified/temporary code — PA rules reference checking the Launch Medication List for up‑to‑date authorization criteria.

ActionFor J3399‑listed medications follow the Launch Medication List guidance: pre‑determination recommended and review 'Review at Launch for New to Market' policy for current PA requirements.

inv-87: Launch Medication List — definition/reference

DefinitionLaunch Medication List — a list of newly marketed or high‑cost medications for which pre‑determination is highly recommended and specific PA/notification instructions apply.

GuidancePre‑determination is highly recommended for drugs on the Launch Medication List; some products require prior notification via vendor (e.g., Cimzia via Magellan at 800‑788‑4005).

Conditional PAUnclassified/temporary codes (C9090, C9149, C9151, C9166, C9167, C9168, C9399, J3490, J3590) require PA only for specified products listed in the document.

inv-88: Pre-determination / Prior notification guidance

DefinitionPre‑determination / Prior notification — recommended or required steps for certain specialty drugs; the policy directs using the Provider Portal or specified vendor notification (e.g., Magellan) where noted.

ExamplesCimzia prior notification must be obtained through Magellan prior notification services at 800‑788‑4005; other Launch List drugs follow portal or phone submission per guidance.

Recommended practicePre‑determination is highly recommended for Launch Medication List drugs; submit PA via UHCprovider.com Prior Authorization and Notification tool or call provided number(s).

inv-89: Proton beam therapy (definition/reference)

DefinitionProton beam therapy — focused radiation therapy using proton beams (positive charge); specific CPT codes for proton beam therapy (e.g., 77520, 77522, 77523, 77525) require prior authorization.

CodesProton beam therapy CPT codes listed include 77520, 77522, 77523, 77525 which are noted as requiring prior authorization.

SubmissionSubmit PA requests via the Prior Authorization and Notification tool on UHCprovider.com or by calling the numbers provided for prior authorization.

inv-90: Site of service (SOS) — outpatient hospital vs ASC distinction

DefinitionSite of service (SOS) rule — prior authorization is required only when the service is requested in an outpatient hospital setting; not required if performed at a participating ASC.

ScopeApplies to services with site‑of‑service restrictions across the Launch Medication List and other procedure sections (e.g., certain surgeries and imaging).

ActionWhen requesting services in an outpatient hospital setting, obtain PA; if the procedure will be performed at a participating ASC, PA is not required per this rule.

inv-91: Outpatient hospital vs ASC distinction for prior authorization

RulePrior authorization is required only when services are requested in an outpatient hospital setting; prior authorization is not required if performed at a participating ambulatory surgery center (ASC).

ExamplesThis site‑of‑service distinction is referenced for procedures such as sinuplasty (CPTs 31295, 31296, 31297) and other outpatient services listed on the Launch Medication List.

Provider actionVerify place of service: if outpatient hospital, submit PA via UHCprovider.com; if performed at participating ASC, PA may not be necessary per the policy's SOS rule.

inv-92: LTSS exemption for sleep studies

ExemptionLong‑term services and supports (LTSS) are exempt from prior authorization for sleep studies — PA is not required when services are provided under New York LTSS.

Standard ruleOtherwise, sleep studies (CPTs 95805, 95811, 95807, 95808, 95810) require prior authorization as noted in the policy.

ActionFor non‑LTSS members obtain PA before sleep studies; for members under NY LTSS, PA is not required per the exemption.

inv-93: Ventricular assist devices (VAD) definition

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

PA requirementImplantation of VADs requires prior authorization; providers should call the notification number on the back of the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management team (855‑282‑8929).

Codes/referenceThe policy references VAD‑related codes and unclassified placeholders (e.g., C9399, J3490, J3590) connected to VAD procedures and devices.

inv-94: Stimulators (implantable) definition

DefinitionStimulators (implantable) — devices implanted to send electrical impulses, including neurostimulators and bone growth stimulators; implantation requires prior authorization.

ExamplesDevice HCPCS/CPT examples in the policy include E0747, E0748, E0749, E0760 and CPTs referenced for neurostimulators and related procedures.

Provider actionObtain prior authorization prior to implantation of stimulators; follow the PA submission instructions in the policy (portal/phone).