CurrentColorado Rocky Mountain Health PlansPolicy PCA-4-24-03748-Clinical-ORG_12302024

Prior authorization requirements for bariatric surgery and related services

Lists prior authorization requirements for inpatient and outpatient bariatric surgery and related obesity services and explains how providers should request authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for bariatric surgery and related services

Policy CodePolicy PCA-4-24-03748-Clinical-ORG_12302024

Change TypeNo material changes

Effective DateApril 1, 2023; July 1, 2024; March 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or by calling 877-542-9231.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredBariatric surgery (inpatient/outpatient)

ExemptEmergency/urgent care

Phone/OnlineRequest methods

4Bariatric CPT examples

>$500Cost threshold for PA

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Coverage Criteria and Applicability

Prior authorization requirements and applicability for services provided to members. Prior authorization is required for the services and codes listed below unless a specific exception is noted. Prior authorization is not required for emergency or urgent care.

ALL of the following

Prior authorization is required for the procedures and services listed in this section unless explicitly noted otherwise (see individual code or diagnosis-level exceptions).
Operational: Submit prior authorization via the payer portal or by phone as specified in general information.
Examples of services commonly requiring prior authorization
- Bariatric surgery (inpatient and outpatient) — e.g., CPT 43644, 43645, 43659, 43770.
  Source: prior authorization list (chunk 2).
- Bone growth stimulators / electronic bone growth stimulation — e.g., HCPCS/CPT 20975, 20979.
  Source: prior authorization list (chunk 2).
- Breast reconstruction and related procedures — multiple CPT/HCPCS codes (e.g., 19316, 19357, 19361, 19364, 19367, 19368–19371, 19380, 19396, L8600). Prior authorization required except where a specific diagnosis-level exception states 'Prior Auth NOT required for diagnosis codes listed below'.
  See chunks 2, 18, 33, 44.
- Cosmetic procedures (generally require prior authorization when billed as reconstructive/cosmetic per plan terms) — e.g., CPT 11960, 14020–14021, 14041, 15820–15823, 15830, 15847, 15877, 15878, 17106–17108.
  Source: chunk 64.
- Durable medical equipment (DME) — many DME items require prior authorization; certain DME require authorization only when retail purchase or cumulative rental cost exceeds $500 — e.g., A9279, A9280, A9900, E0118, E0194, E0265–E0277, E0300, E0328–E0329, E0445, E0457, E0465–E0466, V5281–V5288, E2298.
  See chunks 76, 84, 198, 216, 252.
- Enteral and in-home nutritional therapy services — e.g., B4034–B4036, B4100, B4102–B4104, B4149 — prior authorization required.
  Source: chunk 84.
- Investigational or experimental services and specific procedure codes flagged as investigational — examples include A4638, A6000, A9274, E0231, E1831, S0810, S1030, S9988, S9991, S2102, S9990. These services require prior authorization and may be subject to additional review for investigational status.
  Source: chunk 86.
- Injectable medications — many require prior authorization; follow the payer’s specialty or injectable medication authorization process (examples: J3262, J1552 and product names referenced in the source). Pre-determination is recommended for newly FDA-approved drugs and those on the Review at Launch list.
  Source: chunks 169, 186.

CPT, HCPCS and ICD-10 Code Listings

ICD-10 (skin cancer / neoplasm codes) - consolidatedICD-10

C43.22	Malignant melanoma of left ear and external auricular canal
C43.4	Malignant melanoma of trunk
C44.11	Basal cell carcinoma of lip
C44.111	Basal cell carcinoma of upper lip
C44.112	Basal cell carcinoma of lower lip
C44.1121	Basal cell carcinoma of lower lip, right
C44.1122	Basal cell carcinoma of lower lip, left
C44.119	Basal cell carcinoma of lip, unspecified
C44.1191	Basal cell carcinoma of lip, unspecified - right
C44.1192	Basal cell carcinoma of lip, unspecified - left

1–10 of 28

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Actions for Providers — Authorization, Submission, and Documentation

Prior Authorization

Obtain prior authorization for bariatric surgery

Prior authorization is required for inpatient and outpatient bariatric surgery procedures. Examples of CPT codes listed in the policy include 43644, 43645, 43659, and 43770; requests should be submitted via the payer’s online portal or by phone as described in the policy.

Examples of bariatric CPT codes: 43644, 43645, 43659, 43770

Prior Authorization

Request prior authorization for listed CPT codes

Prior authorization is required for the listed non-mastectomy CPT codes (e.g., 19357, 19361, 19364, 19367). Each code entry in the document is paired with a 'How to obtain prior authorization' instruction indicating providers must request authorization before services are rendered.

Examples: 19357, 19361, 19364, 19367 — 'How to obtain prior authorization' noted for each

Background and Scope

Background: This section is administrative and lists prior authorization requirements for a range of services, including inpatient and outpatient bariatric surgery. Examples of bariatric CPT codes are provided and the document instructs providers to obtain prior authorization via the UnitedHealthcare Provider Portal or by phone. The background emphasizes that prior authorization is required for many listed services while also noting that emergency or urgent care is exempt from prior authorization.

Definitions and Key Terms

Bariatric surgery — prior authorization (definitions)

Prior authorization requiredInpatient and outpatient bariatric surgery require prior authorization

Example CPT codes43644, 43645, 43659, 43770 (listed in policy)

How to requestSubmit via payer portal or phone as specified in policy

Cochlear implant — definition

DefinitionCochlear implant: medical device with internal and external components for patients with profound sensorineural deafness

PurposeHelps individuals achieve conversational speech (document description)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization requirements for bariatric surgery and related services

Policy CodePolicy PCA-4-24-03748-Clinical-ORG_12302024

Change TypeNo material changes

Effective DateApril 1, 2023; July 1, 2024; March 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the UnitedHealthcare Provider Portal or by calling 877-542-9231.

SourceLink

On This Page

Prior Authorization

Prior authorization required for cancer supportive care injectables

Prior authorization is required for certain cancer supportive care outpatient injectables, including colony‑stimulating factor drugs, bone‑modifying agents, and specified antiemetics when administered for a cancer diagnosis.

Examples of codes requiring prior authorization include J1442, J1447, J1448, J2506 and several Q-codes listed in the Cancer Supportive Care section.

Prior Authorization

Obtain prior authorization for cardiology procedures

Prior authorization is required for outpatient and office‑based cardiology services indicated in the policy; providers are instructed to submit requests via the UnitedHealthcare Provider Portal or by phone.

Cardiology prior authorization submission: UHCprovider.com or phone 866-889-8054; see Cardiology Prior Authorization and Notification for specific CPT codes.

Prior Authorization

Prior authorization required for cochlear implants

Prior authorization is required for cochlear implants and other auditory implants; the policy lists specific CPT/HCPCS codes (for example 69710, 69714, 69930, L8614) and notes PA is required when billed with certain diagnoses.

Cochlear implant example codes: 69710, 69714, 69930, L8614 — PA required; accessories/supplies (A4226, A9278, A9276, E0787, E2103) also listed.

Prior Authorization

Submit PA for breast reconstruction codes (unless diagnosis exempt)

Breast reconstruction and related non‑mastectomy reconstruction CPT/HCPCS codes are listed with prior authorization instructions; some diagnosis codes are explicitly noted as not requiring prior authorization in the policy.

Breast reconstruction example CPT/HCPCS: 19368, 19369, 19370, 19371, L8600, 11971; entries note 'Prior Auth NOT required for diagnosis codes listed below' for specified diagnoses.

Prior Authorization

Follow PA instructions for listed CPT/HCPCS codes

The policy lists numerous CPT/HCPCS codes that require prior authorization across cosmetic and reconstructive categories and for devices such as cochlear implants; providers must follow the 'How to obtain prior authorization' instructions paired with each code.

Includes cochlear implant/device codes and many cosmetic/reconstructive CPT/HCPCS entries — follow the paired 'How to obtain prior authorization' instructions.

Prior Authorization

PA required for molecular/genetic tests (asterisk exceptions noted)

Prior authorization is required for a range of molecular and genetic test CPT/HCPCS codes listed in the policy; codes marked with an asterisk do NOT require prior authorization when billed with one of the specified diagnosis (DX) codes.

Several genetic/molecular codes are listed (e.g., 81436*, 81445*, 81479*, 81518*); asterisked codes are exempt from PA when billed with the listed DX codes.

Prior Authorization

Obtain PA per ICD‑10 to CPT/HCPCS mappings

Providers must obtain prior authorization for services identified by the policy’s code‑to‑diagnosis mappings; the document indicates many ICD‑10 codes require PA per the associated CPT/HCPCS mapping shown in the general information section.

The policy maps numerous ICD‑10 codes (C43.x, C44.x and others) to CPT/HCPCS and 'How to obtain prior authorization' instructions — include associated procedure codes when requesting PA.

Prior Authorization

Follow PA instructions for enumerated ICD‑10 code groups

The policy references prior authorization for numerous ICD‑10 code groups (for example C57.10 through C82.35 and related subcodes); providers must obtain authorization as indicated in those entries.

ICD‑10 blocks shown (C57.xx through C82.xx) include 'How to obtain prior authorization' instructions — follow those instructions when submitting requests.

Documentation Required

Include payer internal authorization codes on PA requests

If internal prior authorization codes shown in the policy (for example the C81–C92 series) are missing or incorrect on submission, the request may be denied; include the correct internal PA code and associated CPT/HCPCS codes.

Examples: C81.97–C82.16 and additional C82.* ranges — include the correct internal PA code when submitting requests to avoid denial.

Prior Authorization

Obtain PA for listed injectables, home health, IVIG, radiopharmaceuticals

Prior authorization is required for the injectable medications, home health services, IVIG (90283), and selected therapeutic radiopharmaceuticals listed; submit requests via the payer portal or designated contact methods per the policy.

Examples include home health codes (99504, G0299, G0300, G0493–G0496), IVIG 90283, and multiple J/Q/A codes listed in the Injectable Medications section.

Prior Authorization

Get PA for total hip and knee replacement

Prior authorization is required for total joint replacement (hip and knee) procedures as listed in the policy; entries specify prior authorization is required before these services are provided.

Joint replacement entries indicate 'Prior authorization required' for total hip and knee procedures (codes listed in the Joint replacement section).

Prior Authorization

Obtain PA for specified musculoskeletal procedures

Certain musculoskeletal procedures (for example shoulder surgery) require prior authorization according to the policy; providers should request authorization before performing these services.

Musculoskeletal example: shoulder surgery (CPT 23474) listed with 'Prior authorization required'.

Prior Authorization

Request PA for orthotics/prosthetics when cost > $500

Prior authorization is required for orthotics and prosthetics only when the retail purchase or cumulative rental cost exceeds $500; providers must obtain authorization in those cases.

Cost threshold triggering PA: retail purchase or cumulative rental cost of more than $500 for orthotics/prosthetics.

Prior Authorization

Obtain PA or prior notification for listed injectables

Multiple injectable medications and therapeutic radiopharmaceuticals listed in the policy require prior authorization or prior notification; the policy also recommends pre‑determination for new‑to‑market drugs on the Review at Launch list.

Examples include Cimzia and Synagis (prior notification recommended), J2781 (Synagis), J3316 (Truxima), J3247 (Cosentyx) and various radiopharmaceutical codes (A9590, A9606, A9699).

Documentation Required

Provide PA and cost details for higher‑cost HCPCS L08xx items

When orthotic or prosthetic items (including HCPCS L08xx items) have a cost greater than $500, the policy requires prior authorization or additional administrative review and instructs providers to document the HCPCS code and provide 'Additional Information' about cost.

HCPCS L08xx examples: L0810, L0820, L0830, L0859 — policy flags 'Additional Information = cost of more than $500' and implies PA/administrative review is required when cost exceeds $500.

Documentation Required

Document HCPCS L0810/L0820/L0830/L0859 with cost info when > $500

The policy lists HCPCS L0810, L0820, L0830, and L0859 and flags that 'Additional Information = cost of more than $500,' indicating providers must include cost details and follow PA/administrative review procedures when these codes are billed.

When billing L0810/L0820/L0830/L0859, include the HCPCS code and 'Additional Information' showing item cost when it exceeds $500.

Note

Note HCPCS L08xx codes in PA listings (cost flag present)

The document includes HCPCS L0810, L0820, L0830, and L0859 in its listings; while this fragment does not add further PA details, these codes are repeatedly associated with the cost threshold and 'Additional Information' note in the policy.

HCPCS codes: L0810, L0820, L0830, L0859 — associated with the 'cost of more than $500' notice across multiple entries.

Documentation Required

How to request prior authorization

Submit prior authorization requests using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone per the policy’s instructions.

Online: UHCprovider.com (sign in with One Healthcare ID); By phone: 877-542-9231 or specialty numbers shown (e.g., cardiology 866-889-8054).

Documentation Required

Include procedure codes and internal PA codes on requests

Providers should submit prior authorization requests online via UHCprovider.com or by phone and must include the relevant CPT/HCPCS codes and any payer internal authorization code referenced in the policy when applicable.

Include associated CPT/HCPCS and, when shown, the payer internal PA code (examples in the C81–C92 ranges) on the authorization request.

Documentation Required

Document HCPCS code and cost when requesting PA for high‑cost items

The policy requires providers to document HCPCS codes (for example L0810, L0820, L0830, L0859) and provide 'Additional Information' such as item cost when the cost exceeds $500 as part of the prior authorization submission process.

When item cost exceeds $500, include HCPCS code and 'Additional Information' describing the cost to support the PA request.

Denial Risk

Risk of denial if required PA or codes are missing

Claims submitted without the required CPT or HCPCS codes and/or without the required prior authorization tied to the listed ICD‑10 diagnosis codes may trigger denial; ensure PA is obtained and appropriate codes are included to avoid denial.

Missing required PA or omission of the mapped CPT/HCPCS procedure codes tied to ICD‑10 entries may result in claim denial or non‑payment.

Denial Risk

Denial risk for bariatric surgery without PA

Failure to obtain the prior authorization referenced for bariatric surgery (inpatient and outpatient) may trigger denial or administrative delay; obtain authorization before providing these procedures.

Bariatric surgery entries explicitly state 'Prior authorization required' and the denial‑risk note warns lack of PA may trigger denial.

Cochlear implant — device description

Device componentsInternal component within inner ear and external portion

Clinical useFor profound sensorineural deafness; may require prior authorization when billed with certain diagnoses

Femoroacetabular impingement (FAI) — PA note

PA requirementFAI procedures require prior authorization for members 21 and older

Associated CPT codes29914, 29915, 29916

Internal prior authorization code

Internal authorization codePayer-specific alphanumeric internal codes (examples shown: C82.45–C82.55 and similar ranges)

UsageInclude internal prior authorization code when submitting requests as indicated in policy

HCPCS L08xx DME — note

DME categoryHCPCS L08xx series referenced as durable medical equipment in policy

DocumentationProvide 'Additional Information' when item cost exceeds $500

HCPCS L08xx codes — examples

HCPCS L08xx codesL0810, L0820, L0830, L0859

ContextListed in policy with additional information note when cost > $500