Colorado Rocky Mountain Health Plans Prior Auth

Prior authorization is not required for emergency or urgent care. This policy applies to participating providers in the UnitedHealthcare Community Plan; out-of-network requests must be made by a network care provider. For routine prior authorization submissions, use the UnitedHealthcare Provider Portal or the phone number shown in the policy (see documentation section).

Reference: submit requests via the Prior Authorization and Notification tool on UHCprovider.com or by phone as described in the document.

The policy lists numerous cosmetic and reconstructive procedures and indicates that prior authorization is required for the cosmetic and reconstructive procedure codes shown. It also separately identifies procedures described as “cosmetic procedures that change or improve physical appearance, without significantly improving or restoring,” which are addressed in the document and called out as cosmetic in nature.

When submitting requests for the listed cosmetic or reconstructive CPT/HCPCS codes, follow the standard prior authorization submission channels (UnitedHealthcare Provider Portal or the provider phone number shown).

The policy clarifies that prosthetics are not considered durable medical equipment (DME) for the purposes of this document and directs providers to the orthotics and prosthetics section (HCPCS L‑codes) for prior authorization rules and code lists.

Providers requesting prosthetic devices should reference the orthotics and prosthetics HCPCS L‑code listings in the policy and observe any retail purchase or cumulative rental cost thresholds applicable to those items.

Prior authorization is required only for services performed in outpatient settings, which explicitly includes services delivered in a member's home (home health or other outpatient/home settings). Inpatient services are not subject to these outpatient-only prior authorization requirements per this statement.

When outpatient prior authorization is required, submit requests via the UnitedHealthcare Provider Portal or by the telephone number provided for the relevant service category as noted in the policy.

For requests billed under unclassified or miscellaneous codes (C9399, J3490, J3590), prior authorization is not broadly required except for specific named products. The policy states that prior authorization is required for several specified products billed to these unclassified codes (for example, Ocrevus Zunovo, Pavblu, Ryplazim, Xenpozyme, Altuviiio, Cablivi, and Veopoz).

Providers should identify the specific product when using a miscellaneous/temporary code and follow the policy’s prior authorization instructions for that product (submit via the Provider Portal or the phone number indicated).

The policy includes site-of-service guidance: prior authorization is required only when the service is requested in an outpatient hospital setting for the codes annotated with a site‑of‑service note. For those codes, the additional Site of Service (SOS) — outpatient hospital — triggers the requirement.

Providers scheduling procedures should confirm the site-of-service for the procedure and obtain prior authorization when the service will be provided in an outpatient hospital setting, using the Provider Portal or phone channels described in the document.

The policy specifies that CPT code 38232 will only require prior authorization when billed with an oncology diagnosis. For non‑oncology diagnoses, prior authorization is not required for this code per the document.

When submitting a request involving code 38232, include the diagnosis to demonstrate whether the oncology condition applies and follow the standard prior authorization submission routes.

Codes Requiring Prior Authorization or Noted in Policy

Bariatric / obesity-related CPT/HCPCS codes requiring prior authorizationCPT | HCPCSCovered

43644	CPT listed for bariatric surgery (as provided in document)
43645	CPT listed for bariatric surgery (as provided in document)
43659	CPT listed for bariatric surgery (as provided in document)
43770	CPT listed for bariatric surgery (as provided in document)
43775	CPT listed for bariatric surgery/inpatient and outpatient bariatric services
43847	CPT listed for bariatric surgery/inpatient and outpatient bariatric services
43842	CPT listed for bariatric surgery/inpatient and outpatient bariatric services
43848	CPT listed for bariatric surgery/inpatient and outpatient bariatric services
43845	CPT listed for bariatric surgery/inpatient and outpatient bariatric services
43860	CPT listed for bariatric surgery/inpatient and outpatient bariatric services

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Cardiovascular / vascular ICD-10 codesICD-10

I72.8
I72.9
I77.2
I77.70
I77.72
I74.5
I74.8
I74.9
I75.021

Cardiovascular and musculoskeletal ICD-10 codes (continued)ICD-10

I75.022
T82.818A
S81.809A
M86.051
M86.062
M86.079
M86.10
M86.161
M86.172
M86.20

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Osteomyelitis and cerebral seizure monitoring codesmixed

M86.061
M86.072
M86.1
M86.159
M86.171
M86.19
M86.259
M86.271
M86.29
M86.359

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Devices, continuous glucose monitor, cosmetic/reconstructive CPT/HCPCS/ICD codesmixed

69710	Cochlear implant CPT per document
L8690	Cochlear implant HCPCS per document
69714	Cochlear implant CPT per document
L8691	Cochlear implant HCPCS per document
69930	Cochlear/aural implant CPT per document
L8692	HCPCS
L8614
A4226	Continuous glucose monitor supplies
A9278	Continuous glucose monitor supply
A4238	Continuous glucose monitor supply

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Codes referenced in General informationICD-10 | HCPCS

C43.51
C43.52
C43.59
C43.60
C43.61
C43.62
C43.70
C43.71
C43.72
C43.8

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Durable medical equipment (partial)HCPCSCovered

A9279	Durable medical equipment (DME) code listed
A9280	Durable medical equipment (DME) code listed
A9900	Durable medical equipment (DME) code listed
E0118	DME code listed
E0194	DME code listed
E0265	DME code listed
E0266	DME code listed
E0270	DME code listed
E0277	DME code listed
E0300	DME code listed

Enteral and in-home nutritional (partial)HCPCSCovered

B4034	Enteral services
B4035	Enteral services
B4036	Enteral services
B4100	In-home nutritional therapy / gastrostomy tube related
B4102	In-home nutritional
B4103	In-home nutritional
B4104	In-home nutritional
B4149	In-home nutritional
B4150	Enteral therapy

Femoroacetabular impingement syndrome (FAI)CPTCovered

29914	Femoroacetabular impingement syndrome (FAI) procedure code listed
29915	FAI procedure code listed
29916	FAI procedure code listed

Experimental and investigational (partial)mixedExperimental

36514	Listed under experimental and investigational services
64722	Listed under experimental and investigational services
65765	Listed under experimental and investigational services
66180	Listed under investigational services
A4638	Listed under investigational services
A6000	Listed under investigational services
A9274	Listed under investigational services

Genetic and molecular testing (partial)CPT

81401	Molecular testing (listed); some codes marked with *
81402	Molecular testing (listed)
81403	Molecular testing (listed)
81406	Molecular testing (listed)
81411	Molecular testing (listed)

ICD-10 diagnosis codes (cancer-related list, partial)ICD-10

C00.0	ICD-10 diagnosis codes (cancer list, partial mapping)
C34.01	ICD-10 diagnosis codes (lung cancer subcodes, partial)
C43.11	ICD-10 diagnosis codes (melanoma subcodes, partial)

ICD-10 Codes (C40–C56 and subcodes)ICD-10

C40.22
C40.3
C40.30
C40.31
C40.32
C40.8
C40.80
C40.81
C40.82
C40.9

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ICD-10 (fragmented list)ICD-10

C50.622
C50.629
C50.8
C50.81
C50.811
C50.812
C50.819
C50.82
C50.821
C50.822

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Referenced internal code identifiers (fragment)mixed

C81.23
C81.24
C81.25
C81.26
C81.27
C81.28
C81.29
C81.3
C81.30
C81.31

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Sample CPT/HCPCS codes (partial list)mixed

99504	Home health care (CPT) — listed under Home health care; prior authorization required only in outpatient settings
G0299	Home health care (HCPCS) — listed
G0300	Home health care (HCPCS) — listed
G0493	Home health care (HCPCS) — listed
S9123	Home health care / Actemra (HCPCS) — listed
T1030	Home health / other (HCPCS) — listed
G0496	HCPCS code listed in section
S9474	HCPCS code listed in section
T1021	HCPCS code listed in section
T1031	HCPCS code listed in section

Administration and drug HCPCS/CPT codes (partial)mixed

90283	Medication administration code listed
90284	Medication administration code listed
J1459	Drug/biologic HCPCS code listed
J1554	Drug/biologic HCPCS code listed
J1555	Drug/biologic HCPCS code listed
J1556	Drug/biologic HCPCS code listed
J1557	Drug/biologic HCPCS code listed
J1559	Drug/biologic HCPCS code listed
J1561	Drug/biologic HCPCS code listed
J1566	Drug/biologic HCPCS code listed

Named injectable medications with HCPCS codes (partial list)HCPCS

J0717	Cimzia*
J2786	Cinqair
J3247	Cosentyx
J1551	Cutaquig
Q5128	Cimerli
J3380	Entyvio
J3111	Evenity
J0177	Eylea HD
J0178	Eylea
J1951	Fensolvi

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Injectable medication HCPCS/CPT codes (selected)HCPCSCovered

Q5147	Pavblu
J0897	Prolia
J0802	Purified Cortrophin Gel
C9157	Qalsody
Q5152	Releuko
J1745	Remicade
Q5104	Renflexis
Q5123	Riabni
J9312	Rituxan
J9311	Rituxan Hycela

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Surgical CPT codes requiring prior authorizationCPTCovered

24360	Joint replacement (listed)
24361	Joint replacement (listed)
24362	Joint replacement (listed)
24363	Joint replacement (listed)
23470	Shoulder surgery
21123	Maxillofacial/orthognathic
23473	Shoulder surgery
23474	Shoulder surgery

Orthotics and prosthetics HCPCS L-codes (partial list)HCPCSCovered

L0112	Orthotic/prosthetic HCPCS code
L0464	Orthotic/prosthetic HCPCS code
L0486	Orthotic/prosthetic HCPCS code
L0632	Orthotic/prosthetic HCPCS code
L1000	Orthotic/prosthetic HCPCS code
L1200	Orthotic/prosthetic HCPCS code
L2030	Orthotic/prosthetic HCPCS code
L3265	Orthotic/prosthetic HCPCS code
L5857	Orthotic/prosthetic HCPCS code

Covered HCPCS L-codes (partial)HCPCS

L5647
L5648
L5649
L5651
L5653
L5661
L5673
L5682
L5683
L5700

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Orthotics and prosthetics L-codes (continued)HCPCS

L6010
L6020
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205

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Miscellaneous CPT/HCPCS codes (radiation, chronic care)mixed

99424
99425
33289
T1000
37243
77014	IGRT
77385	IMRT
77386
77520
77522

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Radiation therapy / special services codesmixed

77401
77402
77407
77412
G6003
G6004
G6005
G6006
G6007
G6008

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Surgical and procedural CPT codes (partial)CPT

30400	Rhinoplasty
30410
30420
30430
30435	Septoplasty
30450
30460
30462
30465	Treatment of nasal functional impairment and septal deviation
29805	Arthroscopy (shoulder)

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Procedure codes with noted prior authorization or site-of-service infomixed

20552
20553
21012
21013
21320
30140
30520
43235
43239
43247

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Listed CPT codes (partial)CPT

63303
63304
63305
63306
63307
63308
0098T
58150	Sterilization
58152	Sterilization
58180	Sterilization

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Listed CPT/HCPCS codes (partial)mixed

58275
58290
58291
58292
58542
58543
58544
58550
58552
58553

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Neurostimulator and related codes (partial)mixed

E0749
E0760
43881
43882
61863
61864
61867
61868
61885
61886

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Device/prosthetic codes (partial)HCPCS

64570
64590
L8680
L8682
L8685
L8686
L8687
L8688

Cardiac/transplant related CPT codes (partial)CPT

32850
32851
32852
32853
32854
32855
32856
33930
33933
33935

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Bone marrow / transplant procedure codes (partial)CPT

38208
38209
38210
38212
38213
38214
38215
38232
38240
38241

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Abdominal/hepatic surgery codes (partial)CPT

44132
44133
44135
44136
44137
44715
44720
44721
47133
47135

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Kidney/uro-related codes and miscellaneous (partial)mixed

48551
48552
48554
50300
50320
50323
50325
50340
50360
50365

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Vein procedure codesCPT

36473	Vein procedures
36475	Vein procedures
36478	Vein procedures
37700
37722	Removal and ablation of main trunks and named branches of the saphenous veins
37765
37766

VAD, cardiac function codes and wound vacmixed

33927	VAD
33928	VAD
33929	VAD
33975	VAD
33976
33979
33981
33982
33983
Q0507

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Continuous glucose monitor billing condition — prior authorization required when billed with Type 2 diabetes diagnosis

ConditionPrior authorization is required when continuous glucose monitor (A4238/A4239/A9276/A9277/E0787/E2103/E2102) is billed with a Type 2 diabetes diagnosis

Relevant codesA4238, A4239, A9276, A9277, E0787, E2103, E2102

How to submitSubmit requests online using the UnitedHealthcare Provider Portal (UHCprovider.com) or call the provider number shown in the policy

DME retail purchase threshold — retail purchase or cumulative rental cost greater than $500

ThresholdRetail purchase or cumulative rental cost greater than $500 triggers prior authorization for listed DME/orthotics/prosthetics

Example DME codesA9279, A9280, A9900, E0118, E0194, E0265, E0266, E0270, E0277, E0300

NotesSome E-codes include 'retail purchase or a cumulative rental cost of more' or 'than $500' language in additional information

Retail purchase threshold — than $500

Retail purchase thresholdThan $500 (additional information for listed E-codes indicates retail purchase threshold of $500)

Affected codes (examples)E0328, E0329, E0445, E0457, E0465, E0466

ContextPhrase appears as 'than $500.' in the additional information for listed HCPCS/E-codes

Rental cumulative cost threshold — retail purchase or a cumulative rental cost of more

Rental cumulative cost thresholdPrior authorization required for retail purchase or a cumulative rental cost (language in document: 'retail purchase or a cumulative rental cost of more')

Supporting E-codesE0265, E0266, E0270, E0277, E0300 (listed with cumulative rental language)

ScopeApplies to DME entries listed with 'Additional information' specifying purchase vs cumulative rental cost

BRCA reference — BRCA gene inclusion note for some C44.* codes

BRCA noteDocument notes molecular testing to include breast cancer (BRCA) gene for some C44.* code entries

Example ICD-10 entriesC44.199, C44.20, C44.209, C44.21, C44.219

ActionWhen C44.* codes reference molecular testing, BRCA inclusion is indicated in additional information

Prior authorization presence — placeholders follow ICD codes but no numeric thresholds provided

Presence of PA placeholdersMany ICD-10 code lines include the placeholder text 'CPT ® or HCPCS codes and/or how to obtain prior authorization =' without numeric thresholds

ExamplesC64.2, C65, C79.60, C79.61 (and many others) are shown paired with placeholder PA text

ImplicationPlaceholders indicate associated prior authorization exists but numeric thresholds or specific PA steps are not provided in these fragments

Orthotics/prosthetics prior authorization cost threshold — retail purchase or cumulative rental cost of more than $500

Orthotics/prosthetics PA cost thresholdPrior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500

Referenced L-codesL0112, L0464, L0486, L0632, L0170, L0480, L0624, L0456, L0482, L0629, L0462, L0484

How appliedThreshold language appears in the orthotics and prosthetics section as the trigger for PA

Diagnosis code ranges requiring prior authorization for standard radiation therapy — example ranges C34.00 - C34.92, C50.011 - C50.929, C61

Diagnosis rangesPrior authorization required for standard radiation therapy (2D/3D) only when obtained with diagnosis codes in these ranges: C34.00 - C34.92, C50.011 - C50.929, C61

Procedure typeStandard radiation therapy (2D/3D)

ReferenceSee radiation therapy section where the PA requirement is conditional on these diagnosis ranges

Outpatient therapy visit threshold — prior authorization required after the 12th visit for members 21 and older

Outpatient therapy visit thresholdPrior authorization is required after the 12th visit for members 21 and older (outpatient therapy)

Applies toOutpatient therapy services under physician supervision (listed in therapy/radiation section)

Age conditionMembers age 21 and older

Age threshold for CPT 22865 prior authorization — age 21 and older

Age threshold for CPT 22865Effective Oct. 1, 2024: Prior authorization required for CPT 22865 for members age 21 and older

Effective dateEffective Oct. 1, 2024

Action for providersObtain prior authorization for 22865 when member is age 21+ on/after effective date

Age threshold for 22865 — age 21 and older

Age threshold for 22865Age 21 and older (PA required effective Oct. 1, 2024)

Code22865

NotePolicy explicitly repeats the age 21+ PA requirement for this code

38232 prior auth condition — Code 38232 will only require prior authorization for an oncology diagnosis

38232 prior authorization conditionCode 38232 will only require prior authorization for an oncology diagnosis

ContextListed in the bone marrow / transplant procedure codes section with explicit oncology-only PA note

Implication38232 does not require PA for non-oncology diagnoses per this note

What Providers Must Do / Watch For

Prior Authorization

Prior Authorization Required — Provider Actions

Prior authorization is required for a wide range of devices, procedures, injectable medications, DME/HCPCS items, transplants/CAR T-cell therapy, advanced outpatient imaging, wound vacuum therapy, and certain site-of-service outpatient hospital requests. Submit requests via the UnitedHealthcare Provider Portal (UHCprovider.com) or by the phone numbers shown below. For transplant and CAR T-cell therapy, contact the management team. Ventricular assist device (VAD) cases require notification and faxed case‑management forms.

How to submit prior authorization: Online via the UnitedHealthcare Provider Portal at UHCprovider.com (Prior Authorization and Notification tool) or by phone using the numbers shown in the policy (e.g., 877-542-9231 for general requests; 888-397-8129 for many injectable medications; 888-397-? variants shown in source; 866-889-8054 and 866-889-8054 referenced for some service lines).
Submission channel for miscellaneous HCPCS-coded chemotherapy drugs: Submit requests online using the UnitedHealthcare Provider Portal when a new injectable chemotherapy drug has not yet received an assigned HCPCS code and will be billed under a miscellaneous HCPCS code.
Device/procedure prior authorization codes (selected examples consolidated): Cochlear implants and auditory implants: 69710, 69714, 69930, L8614, L8690, L8691, L8692; Continuous glucose monitors and related HCPCS: A4226, A9278, A4238, A4239, E0787, A9276, E2103, A9277, E2102; Wound vac: E2402; Ventricular assist devices and related CPT/HCPCS shown in VAD section (notification required).
L-code list (partial) — orthotics/prosthetics and related devices (selected ranges shown): L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627, L2628, L3230, L3265, L3649, L5647-L5653, L5661, L5673, L5682-L5683, L5700-L5706, L5716, L5718, L5722-L5728, L5780, L5790, L5795, L5811-L5818, L5822-L5828, L5830, L5845, L5848, L5857-L5858, L5930, L5950, L5960-L5966, L5968-L5979, L5980-L5999, L6000, L7185-L7191, L7405, L8040-L8047, L8499, L8609, L8610, L8612, L8631, L8659.
CPT code list (partial) — examples of procedures requiring prior authorization: Bariatric and obesity-related surgery: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860, 97802; Rhinoplasty/septoplasty: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465; Shoulder arthroscopy codes: 29805–29828 (selected); Sinuplasty: 31298; Colonoscopy/related: 45378, 45380, 45384, 45385; Spinal surgery codes: 22100–22224 and many others with an Oct 1, 2024 note for 22865 for age 21+; Sterilization and gynecologic procedures: 58150, 58152, 58180, 58260–58292, 58542–58573; Joint replacement and maxillofacial/orthognathic examples: 24360–24363, 21121–21215 (selected); Wound vac and DME-related CPT/HCPCS shown separately.
Device/DME prior authorization: Many HCPCS/DME codes require prior authorization (examples: A9279, A9280, A9900, E0118, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470–E0486, E0620, E0636–E0675, E0693–E0710, E2298, and many V- and T- codes). Prior authorization is required when retail purchase or cumulative rental cost exceeds thresholds (for orthotics/prosthetics > $500).
Injectable medications prior authorization: Prior authorization required for many injectable drugs administered outpatient (intravenous, intravesical, intrathecal) including oncology J-codes J9000–J9999 and many specific biologics and specialty injectables (examples from list: Actemra, Cimerli/Q5128, Cimzia*, Cinqair J2786, Cosentyx J3247, Cutaquig J1551, Daxxify, Entyvio J3380, Evenity, Pavblu Q5147, Prolia J0897, Purified Cortrophin Gel J0802, Qalsody C9157, Releuko Q5152, Remicade J1745, Rituxan J9312, Rituxan Hycela J9311, Soliris J1299, Somatuline Depot J1930, Spevigo, Zymfentra J1748, and others). Some medications require alternate prior‑notification routes (e.g., Optum Rx for Cimzia and Synagis at 800‑310‑6826). Effective Oct 1, 2024: PA required for Q5133, Q5135, J1748.
Transplant / CAR T codes and process: Prior authorization and notification required for transplant and CAR T-cell therapy services (includes Carvykti and others). Contact the management team at 888-936-7246 or use the notification number on the back of the member's health plan ID card to obtain authorization and required coordination.
VAD case management contact and process: For ventricular assist devices (VAD), call the notification number on the member's ID card and then fax the form provided by the nurse to the Optum VAD Case Management team at 855-282-8929.
Advanced outpatient imaging (SOS and radiology notification): Prior authorization is required for certain advanced outpatient imaging procedures (selected CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology). Site-of-service rules apply: prior authorization may be required when services are performed in an outpatient hospital setting or other non-participating sites.
Wound vacuum prior authorization: Wound vac therapy requires prior authorization; relevant HCPCS code listed is E2402.
Prior authorization placeholders and multiple lines referencing 'CPT ® or HCPCS codes and/or how to obtain prior authorization' indicate the policy maps ICD-10 headings to CPT/HCPCS codes and submission instructions — consult the corresponding ICD-10/CPT mappings in the full policy when preparing a request.
Denial risk / triggers: No explicit denial triggers are stated within this fragment; however, failure to obtain prior authorization where required (per codes and service lines noted) may result in claim denial or nonpayment.
Provider action summary: Before rendering services listed above, verify the member's plan benefits; obtain prior authorization using the Provider Portal or noted phone numbers; for transplant/CAR T and VAD, follow the special contact and fax processes; for injectable chemotherapy and miscellaneous HCPCS chemotherapy codes, use the Provider Portal when codes are not yet assigned.

OpenPayer

Prior authorization requirements for bariatric surgery and obesity-related services

Coverage Criteria Summary

Codes Requiring Prior Authorization or Noted in Policy

What Providers Must Do / Watch For

Background and Scope Notes