CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

List of services, codes, and submission instructions that require prior authorization for participating UnitedHealthcare Community Plan of Pennsylvania CHIP providers. Applies to inpatient and outpatient services for members of the Pennsylvania CHIP plan.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 888-702-2202, or fax 866-968-7582.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>50service categories or specific codes listed (partial document)

Online, phone, faxsubmission methods for prior authorization requests

100+CPT/HCPCS and DME codes listed or referenced in this extract

Multipleservices explicitly annotated as requiring 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.

DME rental cost threshold mentioned

Services and Situations Requiring Prior Authorization

Partial coverage criteria — prior authorization required

Service-specific prior authorization requirement statements (partial):

Abortion — Prior authorization required for listed CPT/HCPCS codes (e.g., 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857).

Bariatric surgery and obesity-related services — Prior authorization required for listed CPT/HCPCS codes (e.g., 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43860).

BRCA genetic testing — Prior authorization required for listed CPT codes (e.g., 81162, 81212, 81216, 81432).

Cancer supportive care injectables (colony-stimulating factors, certain antiemetics, bone-modifying agents) — Prior authorization required for listed J- and Q-codes (examples include J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125; some codes also require authorization for non-oncology diagnoses).

EEG monitoring authorization rule

Electroencephalography/video monitoring:

Inpatient video EEG (cerebral seizure monitoring) — Prior authorization required for inpatient setting (example CPT codes: 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726). Prior authorization is not required for outpatient hospital or ambulatory surgical center video EEG.

Chemotherapy authorization rule

Outpatient chemotherapy:

Injectable chemotherapy administered in an outpatient setting for a cancer diagnosis — Prior authorization required for chemotherapy injectable drugs (including J9000–J9999), specified agents (e.g., Leucovorin J0640, Levoleucovorin J0641/J0642, Lupron Depot J1950), Q-coded chemotherapy products, and drugs billed under temporary/unassigned codes.

DME and implant authorization rules

Durable medical equipment and implants:

Cochlear and other auditory implants — Prior authorization required for implantable auditory devices (example codes: L8614, 69714, 69930).

Durable medical equipment (DME) — Prior authorization required for listed HCPCS/E-series codes; authorization required for purchases or rentals exceeding specified retail/purchase or cumulative rental cost thresholds (rental/purchase threshold noted at $500).

Prosthetics — Distinct from DME; prosthetic items are addressed in orthotics/prosthetics sections and may have separate prior authorization requirements.

Prior authorization required categories

Prior authorization is required for the following categories and codes as listed below.

Enteral nutrition / in‑home nutritional therapy — Prior authorization required for enteral therapy and related gastrostomy codes (examples: B4034–B4160 range and listed B-codes).

Genetic and molecular testing — Prior authorization required for an extensive list of genetic/molecular CPT/HCPCS and proprietary U-codes; prior authorization may require specifying the performing laboratory and test name and may be specific to outpatient/home settings.

DME, prosthetics and equipment — Prior authorization required for a broad list of E-, K-, S-, T-, and V-series HCPCS codes (selected examples shown); prosthetics are noted as not DME and cross‑referenced to orthotics/prosthetics sections.

Coverage stance for listed codes

Service categories and codes requiring prior authorization or notification include:

Examples

Home health services — Prior authorization required for listed home health codes (e.g., G0156, G0162, G0299, G0300, G0493–G0496).
Hospice services — Prior authorization required for listed hospice codes (e.g., T2045, S9122–S9124, S9474).
Hysterectomy procedures — Prior authorization required for listed hysterectomy CPT codes (examples include 58150, 58152, 58180, 58260–58270, 58542–58553, 58570–58573).
Injectable medications/biologics — Prior authorization required for extensive J- and Q-code lists (see injectable medications section for examples such as J3262, J0801, J1426, J0174 and many others).

Note: For advanced outpatient imaging procedures (certain CT/MRI/MRA/PET and select nuclear medicine), ordering providers are responsible for notification prior to scheduling and must follow the radiology prior authorization process.

Partial coverage criteria from listed codes

Selected coverage rules and requirements referenced in this part of the policy:

Inpatient admissions — Notification required for admissions; prior authorization and notification of admission date required for facilities providing post‑acute care.

Joint replacement (total hip and knee) — Prior authorization required for listed CPT codes (examples include 23470, 24360, 27130, 27132, 27446).

Non‑emergent air transport — Prior authorization required for air/transport HCPCS codes (A0430, A0431, A0435, A0436).

Orthognathic/maxillofacial surgery — Prior authorization required for listed CPT codes (examples include 21121–21127, 21141–21155).

Orthotics and prosthetics — Prior authorization required only for items with a retail purchase or cumulative rental cost greater than $500 (L‑series examples listed in orthotics/prosthetics section).

Prior authorization and notification criteria (partial list)

Prior authorization requirements and notification responsibilities for listed services and codes.

Pediatric day services (PDHC) — Prior authorization required (example code: T1024).

Private duty nursing — Prior authorization required for listed codes (T1000, T1002, T1003).

Potentially unproven services — Prior authorization required for listed codes (examples: 33289, C2624).

Prostate procedures — Prior authorization required for listed prostate procedure codes (examples include 37243, 53852, 52441, 55866, 52442, 55873, 53850, 55874).

Proton beam therapy — Prior authorization required for proton beam therapy CPT codes (77520, 77522, 77523, 77525).

Prior authorization / notification criteria

Services requiring prior authorization or notification:

Spinal surgery — Prior authorization required for an extensive list of spinal CPT codes (examples include 22100–22114, 22206–22214, 22532–22533, 22600, 22800–22819, 63001–63085, 63300–63308, 0098T).

Stimulators / implantable devices — Prior authorization required for many implantable device codes (examples include E0747, E0760, bone growth stimulator codes and spinal stimulator/mode codes such as 63650, 63655; bone growth stimulator codes like 20975/20979 noted elsewhere).

Transplant and CAR T‑cell therapy — Prior authorization required; contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or the notification number on the member's ID card) for transplant and CAR T-cell services (CAR T Q‑codes Q2041–Q2057 referenced).

Gene therapy — Prior authorization required for gene therapy and select J/C codes (examples include C9399, J3391–J3394, J3490, J3590 where listed).

Note: Many services are listed with outpatient hospital site‑of‑service context; review the code lists and site‑of‑service instructions for authorization/notification requirements.

Prior authorization/notification criteria (partial)

Selection of procedures and devices require prior authorization or notification as indicated below.

Vein procedures (saphenous vein removal/ablation) — Prior authorization required for listed CPT codes used to treat venous disease/varicose veins (examples: 36468, 36473, 36475, 36478, 37700, 37718).

Ventricular assist devices (VAD) — Prior authorization/notification required; call the notification number on the member's ID card and fax the form to the Optum VAD Case Management Team at 855-282-8929 per workflow instructions.

Wound VAC (negative pressure wound therapy) — Prior authorization required for listed wound VAC CPT/HCPCS codes (examples include 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982 and supply code E2402).

Codes Referenced — Examples and Groups

Example codes requiring prior authorization (partial list)CPT | HCPCS | ICD-10Covered

59840	Abortion procedure
43644	Bariatric surgery
81162	BRCA testing
J1442	Filgrastim (Neupogen) injectable

Cardiology exception exampleCPT

93580

Cardiovascular code listed as not requiring prior authorization in one note

Injectable chemotherapy J-codes and specific injectablesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin
J1950	Lupron Depot

DME and CGM codesHCPCSCovered

A9276	Continuous glucose monitor related
A9277	Continuous glucose monitor related
A9278	Continuous glucose monitor related
A4226	CGM supplies
E0445	Oxygen contents (example DME code listed)

Selected DME/HCPCS codesHCPCSCovered

E0300	DME code listed requiring prior authorization
E0470	DME code listed requiring prior authorization
K0005	Equipment code listed requiring prior authorization

Genetic and molecular testing codesCPTCovered

81163	Genetic/molecular test code requiring prior authorization
81403	Molecular pathology code requiring prior authorization
81411	Molecular pathology code requiring prior authorization

Selected U-codes (genomic/diagnostic)CPT | HCPCS | mixed

0018U	Genomic/diagnostic test U-code (listed as requiring authorization/notification)
0211U	Genomic/diagnostic test U-code (listed)
0233U	Genomic/diagnostic test U-code (listed)
0417U	Genomic/diagnostic test U-code (listed)

Sample injectable J-codesHCPCSCovered

J3262	Actemra
J0801	Acthar
J1426	Amondys 45
J0174	Leqembi
J2777	Vabysmo
J1427	Viltepso

Selected injectable medication HCPCS/J-codes from this windowHCPCSCovered

J2779	Susvimo
J2777	Vabysmo
J9376	Veopoz
J1427	Viltepso / Vimizim (mentioned)
J7185	Yesintek IV
Q5100	Zinplava
J0565	Zoladex

Air/transport HCPCS codesHCPCSCovered

A0430	Non-emergent air ambulance transport
A0431	Air ambulance transport
A0435	Air ambulance
A0436	Air ambulance

Representative joint replacement CPT codesCPTCovered

23470	Shoulder procedure code (listed among joint replacement section)
27130	Total hip arthroplasty
27446	Knee arthroplasty code

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

L5610	Prosthetic/orthotic HCPCS (example)
L5780	Orthotics/prosthetics examples

Selected services with prior authorization notesCPT | HCPCSCovered

T1024	Pediatric day services (PDHC)
T1000	Private duty nursing
T1002	Private duty nursing
T1003	Private duty nursing
33289	Potentially unproven services (example code listed)
C2624	Potentially unproven services (example code listed)
37243	Prostate procedures (example)
53852	Prostate procedures (example)
77520	Proton beam therapy - planning or delivery (example)
77522	Proton beam therapy (example)

1–10 of 12

1/2

Examples of listed CPT codes across specialtiesCPT

30400	Rhinoplasty/septoplasty etc.
69205	Auditory system procedure example
45378	Colonoscopy
66986	Eye surgery example
49505	Hernia repair example
20680	Musculoskeletal system example

Cell and gene therapy codesHCPCSCovered

Q2041-Q2057	CAR T-cell therapy administration/product codes (range of Q-codes listed)
J3391-J3590	Gene therapy / miscellaneous J-codes referenced

S- and select CPT codesCPT | HCPCS

S2061
S2152
50547

Drug and miscellaneous codesHCPCS

C9399
J3391
J3392
J3393

Vein procedures and wound VACCPT | HCPCSCovered

36468	Vein procedure
36473	Vein procedure
36475	Vein procedure
36478	Vein procedure
33927	Wound VAC related
E2402	Wound VAC supply

inv-29: Outpatient cancer supportive care injectables

RequirementPrior authorization required for outpatient administration of colony-stimulating factors and specified bone-modifying agents for cancer diagnoses (examples: filgrastim J1442/J1449, pegfilgrastim Q5108/Q5111/Q5120/Q5122, denosumab J0897).

ScopeApplies to injectable cancer supportive care drugs administered in outpatient settings (intravenous, intravesical, intrathecal) for cancer diagnoses, including J9000–J9999 chemotherapy range and related Q-codes.

Submission instruction

How to Request Authorization and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

Submit prior authorization requests using one of the following methods: Online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) after signing in with a One Healthcare ID; Phone: 888-702-2202; Fax: 866-968-7582 (fax form available at Prior Authorization Forms). For many specialty services (transplant, CAR T, VAD, certain device programs) follow the specialty contact and fax workflows noted below.

Online: UHCprovider.com Prior Authorization and Notification tab (One Healthcare ID required).
Phone: 888-702-2202.
Fax: 866-968-7582 (use UnitedHealthcare fax form).

Prior Authorization

Inpatient video EEG prior authorization

Prior authorization is required for inpatient video EEG monitoring (inpatient video electroencephalography). Outpatient hospital or ambulatory surgical center video EEG monitoring does not require prior authorization.

Affected CPT codes: 95700, 95711-95716, 95718, 95720, 95722, 95724, 95726.

Key Terms and Process Notes

inv-74: Portal submission via One Healthcare ID

ToolUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID and select the Prior Authorization and Notification tab to submit requests.

Alternate methodsPhone: 888-702-2202; Fax: 866-968-7582 (fax form available at Prior Authorization Forms).

Access helpIf you do not have a One Healthcare ID, visit UHCprovider.com/access to register.

inv-75: Behavioral health prior authorization process

ProcessBehavioral health services may require prior authorization; for specific behavioral health codes and referral requirements, providers should call the number on the back of the member's health plan ID card.

Scope

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, or call 888-702-2202, or fax 866-968-7582.

SourceLink

On This Page

Advanced outpatient imaging — Health care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling; follow the radiology prior authorization process (see radiology prior authorization instructions).

Submit prior authorization requests via the Prior Authorization and Notification tool on UHCprovider.com or as directed in portal instructions.

inv-30: DME rental cost threshold

ThresholdDME rentals require prior authorization when cumulative rental cost exceeds $500.

ExamplesCodes cited with this threshold include E0300, E0328, E0329, E0445, E0470, E0471 (see code list for full details).

Purchase vs RentalPolicy references both retail purchase and cumulative rental cost when applying authorization thresholds.

inv-31: Orthotics/prosthetics prior authorization threshold

ThresholdPrior authorization required only for orthotics and prosthetic items with a retail purchase or cumulative rental cost greater than $500.

ExamplesRepresentative L‑codes listed include L0112, L0170, L0456, L0462 and many additional L‑series codes shown in the orthotics/prosthetics section.

DistinctionProsthetics are distinguished from DME; orthotics/prosthetics section cross-references prosthetics-not-DME guidance.

Prior Authorization

Enteral services prior authorization

Enteral nutrition and in-home nutritional therapy (enteral or via gastrostomy tube) require prior authorization. Submit requests online via the Prior Authorization and Notification tool.

Affected HCPCS/Codes: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4155, B4158-B4160, B9002, B9998.

Prior Authorization

DME / prosthetics / HCPCS prior authorization

Durable medical equipment (DME), prosthetics, orthotics and many HCPCS items require prior authorization. Authorization is required for listed DME/HCPCS codes and for prosthetic/orthotic items with retail purchase or cumulative rental cost above the threshold. Submit requests online via the Prior Authorization and Notification tool.

Examples of DME/HCPCS requiring prior authorization: A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0460, E0465, E0466, E0470-E0471, E0483, E0486, E0620, E0636-E0637, E0652-E0675, E0693-E0710, E0745, E0762, E0764, E0766, E0784, E0984-E1009, E8000-E8002, K0005, K0008, K0013, K0108, K0812, K0830-K0831, K0848-K0864, K0868-K0879, K0880, K0884-K0891, S1040, T1999, T5999, V2786, V5269-V5283, V5274-V5283 (and many L- and V- series codes).
Orthotics/prosthetics threshold: prior authorization required only for orthotics/prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.
Prosthetics note: prosthetics are not considered DME; follow orthotics/prosthetics workflow.

Prior Authorization

Procedural CPT codes prior authorization

Many procedural CPT codes across surgical specialties require prior authorization. For site-of-service outpatient hospital advanced procedures (including numerous musculoskeletal, integumentary, nervous system and other CPT codes) submit prior authorization requests online or call the number indicated for radiology/cardiology where applicable.

Ordering providers are responsible for notification prior to scheduling advanced outpatient imaging.
For cardiology/advanced imaging prior authorization phone: 866-889-8054.
Examples: arthroscopic and musculoskeletal procedures (29835, 29840, 29845, 29846, 29848, 29861, 29875-29882, 29888, 29893), select integumentary and biopsy codes (10121, 11440, 11450, 11624, 13121, 15100, 15120, 15240), and many others listed in site-of-service sections.

Prior Authorization

Prior authorization required — test, genomic and selected CPT/HCPCS codes

Prior authorization is required for many laboratory, genetic, molecular and genomic tests (including listed CPT/U-codes and other test-specific codes). The prior authorization/notification process may require the testing laboratory and clinical documentation to complete the review.

Examples of test/genomic codes requiring prior authorization: 81162, 81163, 81164, 81212, 81216, 81228, 81229, 81400-81406, 81432, 81519-81523, 81541-81552, 87505-87507, select proprietary U-codes (0018U, 0022U, 0023U, 0026U, 0037U, 0047U, 0048U, 0050U, 0055U, 0060U) and other listed molecular/genomic codes.
Operational note: include laboratory identity and necessary clinical information when submitting authorization requests to expedite review.

Prior Authorization

Home health, hospice and hysterectomy prior authorization

Home health and hospice services require prior authorization. Home health services require authorization for services provided in outpatient settings as noted; some home health may require only notification depending on setting. Hysterectomy procedures require prior authorization.

Home health examples: G0156, G0162, G0299, G0300; outpatient home health/service codes: G0493-G0496, S9122-S9124, S9474.
Hospice example: T2045 (prior authorization required).
Hysterectomy examples requiring prior authorization: 58150, 58152, 58180, 58260, 58262-58270, 58542, 58290-58292, 58543, 58553, 58573, 58544, 58570, 58550, 58571, 58552, 58572, 58543-58553, 58570-58573.

Prior Authorization

Non-emergent air and ambulance transport prior authorization

Non-emergent air transport requires prior authorization. Ground ambulance transport codes also require prior authorization or follow the transport notification rules.

Non-emergent air transport HCPCS: A0430, A0431, A0435, A0436 — prior authorization required.
Ambulance/ground transport examples: S9960, S9961 (prior authorization required).
Follow applicable notification and prior authorization rules for inpatient admissions associated with transport requests.

Prior Authorization

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics require prior authorization only when the retail purchase or cumulative rental cost exceeds the threshold (more than $500). Follow DME/orthotics and prosthetics workflows for submission.

Threshold: Retail purchase or cumulative rental cost > $500 triggers prior authorization.
Examples of L-codes included: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631-L0640, L0700-L0710, L0810-L0830, L0859, L1000-L1970, L2000, and additional L-series and L86xx codes listed in the policy.

Prior Authorization

CAR T-cell therapy and transplant prior authorization / notification

For CAR T-cell therapy, transplant services and related high-acuity services, contact the UnitedHealthcare Community and State Transplant Case Management Team for prior authorization and notification. Specific CAR T and transplant Q- and S-codes are subject to prior authorization and specialized case management.

Call UnitedHealthcare Community and State Transplant Case Management Team: 888-936-7246 (or the notification number on the back of the member's ID card) for CAR T and transplant services.
CAR T / transplant codes referenced: Q2041, Q2042, Q2053-Q2058, and certain 38232 variations; related Q- and J- codes (e.g., CAR T-specific codes) require prior authorization.
Operational note: follow the transplant/CAR T intake instructions and include required clinical documentation and facility planning information when submitting requests.

Prior Authorization

Gene therapy and select drug-code prior authorization

Gene therapies, certain J- and C-codes, and other high-cost or one-time therapies require prior authorization. Follow the specialty workflows and include supporting documentation about indication, prior treatments and the dispensing provider/laboratory.

Gene therapy and related codes requiring prior authorization or case review include J3391-J3394, J3398, J3490**, J3590**, C9399**, and other gene therapy-designated codes.
Some high-cost drug/admin codes (Q- and J-codes) and CAR T-related codes are listed across the transplant and gene therapy sections and require specialized authorization.
Operational note: provide clinical rationale, prior therapy history, and the performing/supplying facility or laboratory when requesting authorization.

Prior Authorization

VAD and wound VAC authorization and notification

Ventricular assist devices (VAD) and negative-pressure wound therapy (wound VAC) require prior authorization or notification through specialized teams. Follow the Optum VAD Case Management Team workflow for VAD requests.

VAD workflow: Call the notification number on the member's ID card, then fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.
Wound VAC prior authorization: CPT/HCPCS and related codes including 33927-33929, 33975-33982 and E2402 are listed and require prior authorization.
Operational note: include device plan, indication, and facility care plan with the authorization request to facilitate review and case management.

Applies to mental health and substance use services provided through designated behavioral health networks as indicated by the member's plan.

Provider actionContact the phone number on the member ID for plan-specific prior authorization instructions and code lists.

inv-76: Inpatient video EEG definition

DefinitionInpatient video EEG (cerebral seizure monitoring) — continuous video electroencephalography monitoring codes include 95700, 95711–95716, 95718, 95720, 95722, 95724, 95726.

Authorization rulePrior authorization required for inpatient video EEG monitoring; prior authorization is not required for outpatient hospital or ambulatory surgical center video EEG monitoring.

Setting notePolicy explicitly differentiates inpatient (requires authorization) from outpatient settings (authorization not required).

inv-77: Injectable chemotherapy (outpatient) definition

DefinitionInjectable chemotherapy (outpatient): chemotherapy injectable drugs (J9000–J9999), select J-codes (e.g., J0640, J0641, J0642, J1950) and chemotherapy Q-codes administered in outpatient settings for a cancer diagnosis.

Authorization rulePrior authorization is required for injectable chemotherapy drugs administered in outpatient settings (including IV, intravesical and intrathecal) for cancer diagnoses.

Unassigned codesIncludes chemotherapy drugs billed under temporary or not-yet-assigned codes billed under a J- or Q-code as noted in the policy.

inv-78: Cochlear implants and auditory implants definition

DefinitionCochlear implants and other auditory implants are medical implantable devices to restore auditory function (examples: HCPCS L8614; CPTs 69714, 69930).

Authorization rulePrior authorization is required for cochlear and other auditory implant procedures and related device codes.

Coding examplesDocument lists CPT codes 69714 and 69930 and HCPCS L8614 as examples in the cochlear implants section.

inv-79: Prosthetics vs. DME

DefinitionProsthetics are explicitly noted as not being considered durable medical equipment (DME); see orthotics and prosthetics sections for separate guidance.

Cross-referencePolicy cross-references prosthetics to the orthotics/prosthetics section where separate L‑code lists and thresholds are provided.

Authorization implicationBecause prosthetics are distinguished from DME, prosthetic items follow orthotics/prosthetics prior authorization rules rather than DME thresholds.

inv-80: Genetic/molecular testing prior authorization

RequirementGenetic and molecular testing codes require prior authorization; authorizations may require specifying the performing laboratory and the test name.

Setting noteMany molecular/genomic tests are noted as outpatient procedures; some entries reference home care professionals or requesting laboratory details.

Code examplesListed codes include CPTs 81412–81417, 81431, 81435, 81518, 81519–81522, U‑codes (0018U, 0022U, 0023U, etc.) and multiple other U-codes requiring authorization/notification.

inv-81: Prior authorization/notification definition

DefinitionPrior authorization/notification — the process whereby the ordering provider, laboratory, or facility must obtain authorization or provide notification to UnitedHealthcare before performing a service or test listed in this policy.

Who must actOrdering provider or performing laboratory is responsible for submitting the prior authorization or notification as specified in the policy entries (e.g., genetic tests, advanced imaging).

Submission methodsRequests may be submitted via the Provider Portal Prior Authorization and Notification tool, phone lines, or fax per the policy instructions for the service category.

inv-82: Orthotics/prosthetics prior authorization threshold definition

Threshold definitionOrthotics/prosthetics items require prior authorization only when the retail purchase price or the cumulative rental cost exceeds $500.

ScopeApplies to the L‑code orthotics/prosthetics lists provided in the policy; many L‑series codes are enumerated under this rule.

Action for providersObtain prior authorization when an orthotic or prosthetic item's retail purchase or cumulative rental cost will exceed $500 prior to ordering/scheduling.

inv-83: Inpatient admission notification/prior authorization

RequirementNotification is required for inpatient admissions; some post-acute facilities require both prior authorization and notification of the admission date.

VAD-specific workflowVentricular assist devices (VAD) require prior authorization/notification — providers should call the notification number on the member's ID card and fax the form provided by the nurse to the Optum VAD Case Management Team at 855-282-8929.

Inpatient vs OutpatientPolicy distinguishes inpatient notification/prior authorization requirements from outpatient procedures (e.g., inpatient EEG requires authorization while outpatient EEG does not).

inv-84: Proton beam therapy definition

DefinitionProton beam therapy — focused radiation therapy using beams of protons; CPT examples include 77520, 77522, 77523, 77525.

Authorization rulePrior authorization is required for proton beam therapy services.

Coding examplesPolicy lists CPT codes 77520, 77522, 77523 and 77525 as examples under proton beam therapy requiring prior authorization.

inv-85: Advanced outpatient imaging definition

DefinitionAdvanced outpatient imaging includes certain CT, MRI, MRA, PET scans, nuclear medicine and nuclear cardiology procedures.

Provider responsibilityHealth care professionals ordering advanced outpatient imaging are responsible for providing notification prior to scheduling the procedure.

How to requestSubmit prior authorization requests online via the Prior Authorization and Notification tool on UHCprovider.com or call 866-889-8054 for radiology-specific prior authorization details.

inv-86: Transplant Case Management Team

TeamUnitedHealthcare Community and State Transplant Case Management Team — contact at 888-936-7246 for transplant and CAR T-cell therapy authorization/notification.

When to callCall for authorization/notification for transplant and CAR T-cell therapy services (examples: Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) as specified in the transplant section.

AlternateProviders may also use the notification number on the back of the member's ID card as directed by the policy.

inv-87: Prior authorization definition

DefinitionPrior authorization — authorization required before the service is performed for specified procedures such as spinal surgery, implantable stimulators, transplants, CAR T-cell therapy and gene therapy.

ExamplesPolicy lists spinal surgery CPTs, stimulator/device HCPCS, transplant/CAR T and gene therapy codes as services that require prior authorization.

Provider actionObtain prior authorization via the portal, phone or specific specialty workflows (e.g., transplant case management) before scheduling the service.

inv-88: Ventricular assist devices (VAD) definition

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

Authorization instructionPrior authorization required; call the notification number on the back of the member's ID card and fax the nurse-provided form to the Optum VAD Case Management Team at 855-282-8929.

Coding examplesPolicy lists multiple VAD-related CPT/HCPCS codes (e.g., 33976, 33979, 33981, 33982 and E2402 in wound vac context) in the VAD/wound vac sections.

inv-89: Wound vac definition

DefinitionWound vac — negative pressure wound therapy; several CPT/HCPCS wound VAC codes are listed (33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982, E2402).

Authorization ruleSome wound VAC codes require prior authorization as noted in the policy; E2402 is listed among HCPCS examples.

Related proceduresWound VAC entries appear alongside transplant and VAD guidance in the Authorization and Notification section; follow specified authorization workflows.