UnitedHealthcare Maryland Prior Auth Policy Update

Services and Codes Requiring Prior Authorization

Prior authorization coverage criteria (examples present in this part of the document)

Covered when indicated below; emergency or urgent care does not require prior authorization.

Prior authorization is required for the services and codes listed below unless otherwise noted (emergency/urgent care excluded).

Examples

Abortion (pregnancy termination): prior authorization required; providers should call the number on the back of the member's ID card for authorization.
Acupuncture (CPT 97811, 97814; HCPCS S8930): prior authorization required.
Bariatric surgery and specific obesity-related services (examples: CPT 43644, 43775, 43645, 43842): prior authorization required.
Cancer supportive care — colony-stimulating factors and bone-modifying agents administered outpatient for a cancer diagnosis (examples: J1442, J2506, J1449, J0897): prior authorization required; selected J/Q codes also require PA for non-oncology indications.
Cardiology outpatient and office-based diagnostic procedures (echocardiograms, electrophysiology implants, stress echoes and specified CPT/HCPCS): prior authorization required; use the Prior Authorization and Notification tool or call 866-889-8054.

How to request prior authorization: submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the listed phone numbers; out-of-network providers must request prior authorization for non-emergent services.

Routing to detailed prior authorization criteria

Routing note — this section points providers to online, service-specific prior authorization resources rather than providing full clinical criteria.

For detailed CPT/HCPCS lists and clinical criteria for cardiology and other service areas, providers should visit UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources (Cardiology Prior) or use the provider portal prior authorization tile.

This extract does not duplicate full clinical criteria; it references ICD-10 diagnosis groupings (e.g., I70.* series) tied to prior authorization for cardiovascular services and directs providers to the online resource for code-level guidance.

Prior authorization coverage pointers (excerpt)

Pointers and provider instructions relevant to prior authorization.

Providers are directed to UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for CPT/HCPCS codes and prior authorization procedures.

Cardiology outpatient diagnostics (including echocardiograms, electrophysiology implants and stress echoes) require prior authorization for participating physicians; follow portal or phone process described on the website.

Numerous ICD-10 diagnosis codes (examples: I70.25, I70.261–I70.263, I70.561–I70.568 and related vascular codes) are enumerated in the policy as linked to prior authorization for cardiovascular services; consult the online resource for mapping to CPT/HCPCS codes.

Prior authorization requirements (partial list)

Partial list of service categories and conditions that require prior authorization.

Outpatient injectable chemotherapy administered intravenously, intravesically or intrathecally for a cancer diagnosis (includes J9000–J9999, J0640–J0642, J1950 and other chemotherapy J/Q codes): prior authorization required; submit via provider portal or call 888-397-8129.

Selected cochlear and other auditory implants (examples: CPT 69710, 69711, 69714, 69930): prior authorization required.

Glucose monitors and specified DME when billed with required diagnoses (examples: A4226, A9278, E0787): prior authorization required where indicated.

Durable medical equipment (selected E-/K-series HCPCS listed in the policy): prior authorization required for the listed codes or when retail purchase or cumulative rental cost exceeds $500.

Prior authorization required for listed HCPCS codes

HCPCS entries shown in the document that indicate injectable chemotherapy and related items require prior authorization.

The policy lists numerous HCPCS codes associated with injectable chemotherapy and related services (examples repeatedly shown: E2300, E2301, E2310, E2311, E2322, E2230, E2228, E2227); these HCPCS entries require prior authorization per the policy extract.

Prior authorization criteria sets

Grouped criteria sets and service categories requiring prior authorization (selection shown).

Enteral / In‑home nutritional therapy (enteral or via gastrostomy tube) — prior authorization required for listed B‑codes (e.g., B4034, B4035, B4036, B4100, B4102–B4161).

Experimental / Investigational services — prior authorization required for services designated as investigational (examples listed include CPT 33477, 36514, 64722, 65765 and HCPCS A4638, A6000, S‑codes shown).

Durable medical equipment and supplies — multiple E‑ and K‑series HCPCS codes require prior authorization as enumerated in the policy extract (examples include E2325, E2331, E2351, K0005, K0830 and related entries).

Injectable chemotherapy–related HCPCS codes — multiple E‑series HCPCS codes (e.g., E2227, E2228, E2230, E2300–E2311 range) are listed as requiring prior authorization.

Selected surgical/procedural codes — certain surgical/procedural CPT codes (including femoroacetabular impingement procedures 29914–29916, functional endoscopic sinus CPT 31240–31257, and numerous reconstructive/plastic codes) are listed as requiring prior authorization.

Prior authorization requirement by code (partial)

Partial, code-level requirement notes and exceptions.

A long listing of CPT/HCPCS and laboratory/procedure codes in the policy window are designated as requiring prior authorization; some lines include an explicit exception note (e.g., '*Prior authorization not required when billed with the following'). Providers must review code-level entries for any 'not required when billed with' exceptions.

Prior authorization coverage criteria (codes listed)

Service groups (genetic/molecular testing, specialty injectables) that require prior authorization.

Genetic and molecular testing (including BRCA and other molecular pathology/genomic CPT codes such as 81120–81166, 81208, 81216, 81228–81277 and numerous 814xx/815xx entries): prior authorization required for outpatient testing as listed.

Genomic sequencing and biomarker assays (numerous 814xx, 815xx and proprietary U‑codes) — prior authorization required; consult the policy for the complete code set.

Injectable medications and specialty J‑/Q‑codes (selected J3262, J0791, J1931, J0225, J0256, Q5121, J0490, J0179, J0597, J0585, J0567 and others listed): prior authorization required per the injectable medications section.

Home health outpatient services and hearing aid services — prior authorization required for the listed G‑ and V‑codes in the policy extract.

Injectable medications — prior authorization list (partial)

Partial injectable medication list (code-level entries shown; clinical criteria not provided in this fragment).

The policy lists multiple injectable medications (J‑ and Q‑codes) that require prior authorization (examples include J3262, J0791, J1931, J0225, J0256, Q5121, J0490, J0179, J0597, J0585, J0567, J2329, J0223, J3245, Q5103 and J1439 among others).

Prior authorization requirement — injectable medications (partial)

Additional injectable medication entries and authorization expectation.

Prior authorization is required for the injectable specialty medications listed (examples in this partial window: J1726, J1729, J2675, J3397, J1437, J1458, J0219, J2796, J2182, J2350, J2354, J0222, J0129, J0224, J1576, J0606, J0897, J1301, J0896, Q5125, J1745, Q5104, Q5123, J9312, J9311, J2998, J2353, J1449, J0596). Providers must submit PA requests per payer instructions; clinical criteria are not included in this fragment.

Some entries are partial or repeated in the source; consult the full policy or portal for the complete, authoritative list and any clinical criteria required for approval.

Supprelin coding entries

Coding note for Supprelin.

HCPCS Q5127 is listed in the policy associated with Supprelin and referenced for prior authorization purposes; the source shows repeated Q5127 entries tied to Supprelin.

Prior authorization criteria (section)

Rules and special conditions from the prior authorization section.

J0897 (Denosumab/Prolia/Xgeva) — prior authorization is required only for non‑oncology indications; oncology indications are exempt per the conditional note.

Inpatient stays — prior authorization required for all inpatient stays per the policy extract.

Joint replacement (total hip and knee) and listed related CPT codes — prior authorization required.

Orthognathic surgery (maxillofacial/jaw functional treatment) — prior authorization required for listed CPT codes (examples shown: 21121–21127, 21141–21147, 21150–21159).

The policy also lists that specified injectable medications and therapeutic radiopharmaceuticals included in the document require prior authorization; providers should check the portal for submission instructions.

J0897 PA condition

Conditional prior authorization rule for a specific J‑code.

Prior authorization required only for non‑oncology indications (J0897).

Outpatient therapy PA

Outpatient therapy codes that require prior authorization with an age condition noted in the source.

Outpatient therapy CPT codes (examples include 92507, 92508, 92526, 92630, 92633, 97010–97039, 97110, 97112, 97113, 97116, 97124, 97129–97140, 97150–97156) are listed as requiring prior authorization.

The source notes prior authorization is required for members ages 21 and older for outpatient therapy entries (source phrase is incomplete in the extract); confirm age applicability on the portal or policy details.

Orthotics/prosthetics L-codes

Orthotics and prosthetics L‑code listing and cost threshold for prior authorization.

Multiple orthotics/prosthetics L‑codes are listed as subject to prior authorization (sample L codes in the extract: L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820, L1832, L1834, L1840–L1846 etc.).

Orthotics/prosthetics prior authorization threshold: PA is required for the listed L‑codes when the retail purchase price or cumulative rental cost is greater than $500.

Prior authorization coverage criteria (fragment)

Fragmented coverage criteria and grouped service categories requiring prior authorization.

ANY of the following

Outpatient therapy: Selected outpatient therapy codes (e.g., 97016, 97110, 97116, 97124, 97129, 97130, 97150) are listed as requiring prior authorization.
Pain management: Pain injections and management (examples: 64490, 64493) require prior authorization.
Private duty nursing (examples: T1002, T1003) require prior authorization.
Radiation therapy: Advanced and certain radiation therapy codes (examples: 77385, 77401, 77520, 77522, 77371–77373) require prior authorization; some standard radiation therapy codes require PA only when billed with specified cancer diagnosis code ranges.

Prior authorization criteria by service

Service‑based prior authorization rules and representative code listings.

Sleep apnea procedures (examples: 21685, 41599, 42145) require prior authorization.

Sleep studies / polysomnography (examples: 95805, 95807) require prior authorization.

Spinal surgery — numerous spinal surgery CPT codes are listed as requiring prior authorization (examples include 22100, 22101, 22102, 22110, 22206, 22207, 22210, 22510–22514, 22612, 22630, 22800, 22804, 22818, 22830, 22849–22861, 63001–63064 and others shown across the extract).

Code Lists and Special Coding Rules

Acupuncture codesCPTCovered

97811	Acupuncture
97814	Acupuncture
S8930	Acupuncture HCPCS

Breast reconstruction/mastectomy codesCPT | HCPCSCovered

19316	Breast reconstruction
19330	Breast reconstruction
L8600	Breast prosthesis

Cancer supportive care injectable drugsHCPCSCovered

J1442	Filgrastim (Neupogen)
J2506	Pegfilgrastim (Neulasta)
J1449	Eflapegrastim (Rolvedon)
J0897	Denosumab (Xgeva)

Referenced diagnosis codesICD-10

I70.*

Multiple I70 ICD-10 codes referenced (examples include I70.25, I70.261, I70.262, I70.263)

Sample ICD-10 codes listedICD-10

I70.561	ICD-10 code referenced for prior authorization (cardiovascular)
I72.3	ICD-10 code referenced
M86.051	ICD-10 code referenced (osteomyelitis variants listed)
T82.818A	ICD-10 code referenced

Injectable chemotherapy codesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin (other)
J1950	Leuprolide acetate (Lupron) depot

Selected DME/device HCPCS codesHCPCSCovered

E1004	Example DME HCPCS listed repeatedly in document
E1238	Example DME HCPCS listed repeatedly in document
E2311	Example DME HCPCS listed repeatedly in document

Injectable chemotherapy HCPCS codesHCPCSCovered

E2300	HCPCS injectable chemotherapy code listed
E2301	HCPCS injectable chemotherapy code listed
E2310	HCPCS injectable chemotherapy code listed
E2311	HCPCS injectable chemotherapy code listed
E2322	HCPCS injectable chemotherapy code listed
E2230	HCPCS injectable chemotherapy code listed
E2228	HCPCS injectable chemotherapy code listed
E2227	HCPCS injectable chemotherapy code listed

Sample codes referencedHCPCS

E2230	Durable medical equipment / injectable therapy related HCPCS code (listed repeatedly)
E2300	HCPCS code listed for prior authorization
E2301	HCPCS code listed for prior authorization
K0830	K-code for DME/supplies listed
B4034	Enteral nutrition code (also appears in authorization module)

Procedure codes (sample entries from long list)CPTCovered

11980	CPT/HCPCS code listed in document
14020	CPT/HCPCS code listed in document

Diagnosis codes (sample entries)ICD-10Covered

C43.0	ICD-10 diagnosis code listed in document
C44.01	ICD-10 diagnosis code listed in document

molecular/genomic codesCPT | HCPCS | mixed

81400-81479	Various genomic sequencing and analysis CPT codes listed
81507-81599	Molecular pathology/biomarker codes
0006M-0300U	Multiple proprietary lab (U-) and M- codes listed

surgical codesCPT

58150-58573

Hysterectomy CPT codes that require prior authorization

Highlighted HCPCS codes in this segmentHCPCSCovered

J9217	Luxturna
J3398	Luxturna (alternate/code pairing shown)
J1439	IVIG / injectable chemotherapy entry

Injectable specialty medications (sample)HCPCSCovered

J1726	Makena/17P
J1729	Makena (alternate)
J2675	(listed)
J3397	Mepsevii
J1437	Monoferric
J1458	Naglazyme
J0219	Nexviazyme
J2796	Nplate
J2182	Nucala

Additional HCPCS referencesHCPCSCovered

J9312	Rituxan Hycela
J9311	Roctavian
J2998	Ryplazim
J2353	Sandostatin LAR

Luxturna listingsHCPCSCovered

J9217

Luxturna

Supprelin HCPCSHCPCSCovered

Q5127

HCPCS code referenced for Supprelin

Selected injectable and specialty drug HCPCS/J-codesHCPCSCovered

Q5127	Frequently referenced HCPCS Q-code for specific drug products (e.g., Supprelin)
J3315	Trelstar
J3316	Triptodur
J9381	Tzield
J1303	Ultomiris

Colony stimulating factorsmixedCovered

J1442	White blood cell colony stimulating factor
Q5101	Colony stimulating factor Q-code

Selected outpatient therapy CPT codesCPT

92507	Speech-language evaluation/therapy code (listed in outpatient therapy section)
97110	Therapeutic exercise (listed in outpatient therapy section)
97156	Family training/counseling (listed in outpatient therapy section)

J-code with conditional PAHCPCS

J0897

Drug/biologic code with prior authorization condition noted (PA required only for non-oncology indications)

Outpatient therapy CPT/HCPCS codesCPTCovered

97016	Outpatient therapy (CPT/HCPCS) listed
97110	Outpatient therapy (CPT/HCPCS) listed
97116	Outpatient therapy (CPT/HCPCS) listed

Radiation therapy and associated codesCPTCovered

77385	IMRT planning/management
77401	Radiation therapy (standard)
77520	Proton beam therapy

Pain management and nursingHCPCSCovered

64493	Nerve block, related to pain injections
T1002	Private duty nursing

Surgical procedure groups requiring prior authorizationCPTCovered

30400	Rhinoplasty/septoplasty
29805	Arthroscopy procedures (shoulder)
31295	Sinuplasty

Ophthalmologic codesCPTCovered

65820	Ophthalmologic procedure code referenced for prior authorization
66250	Ophthalmologic procedure code referenced for prior authorization
66710	Ophthalmologic procedure code referenced for prior authorization
66711	Ophthalmologic procedure code referenced for prior authorization
66825	Ophthalmologic procedure code referenced for prior authorization
66986	Ophthalmologic procedure code referenced for prior authorization

Musculoskeletal codesCPTCovered

20552	Musculoskeletal injection/aspiration codes
20553	Musculoskeletal injection/aspiration codes
29806	Arthroscopy-related code
29835	Arthroscopy-related code
29840	Arthroscopy-related code

DME prior authorization cost threshold

ThresholdPrior authorization required only for DME codes listed when retail purchase or cumulative rental cost exceeds $500.

Applies toDurable Medical Equipment (selected E- and K- series HCPCS) listed in the policy.

How enforcedPA indicated on listed HCPCS lines; provider must submit PA when purchase/rental cost > $500.

Orthotics/prosthetics prior auth cost threshold

ThresholdPrior authorization required only for orthotics and prosthetic codes listed when retail purchase or cumulative rental cost is more than $500.

ScopeApplies to listed L‑codes for orthotics and prosthetics in the policy.

Reference textPolicy notes: 'Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.'

Age threshold

Age thresholdPrior authorization required for outpatient therapy codes for members ages 21 and older.

Applies toOutpatient therapy CPT/HCPCS codes listed (examples: 92507, 97110, 97156, etc.).

Source noteSource text fragment: 'Outpatient therapy, Additional information = Prior authorization required for members ages 21 and.'

J0897 oncology exception

ConditionPrior authorization for J0897 (denosumab) is required only for non‑oncology indications.

ImplicationIf J0897 is billed for an oncology diagnosis, PA is not required per this document's note.

Related guidanceSee 'Review at Launch for New to Market Medications Policy' for additional drug launch review information referenced in the policy.

How Providers Request Authorization and What to Do

Prior Authorization

How to request prior authorization

To request prior authorization submit online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 877-842-3210. Prior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures and services excluding emergent or urgent care.

Prior Authorization

Examples of codes requiring prior authorization

Examples include acupuncture (CPT 97811, 97814; HCPCS S8930) and bariatric surgery codes (e.g., CPT 43644, 43775) which are listed as requiring prior authorization.

Prior Authorization

Cancer supportive care medications

Injectable colony‑stimulating factors and certain bone‑modifying agents administered outpatient for a cancer diagnosis require prior authorization; examples listed include J2506, Q5101, J1442, J1449 and J0897.

Prior Authorization

Cardiology prior authorization process

Cardiology outpatient and office‑based diagnostic procedures require prior authorization for participating physicians; providers should use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866‑889‑8054.

Note

Where to find cardiology prior authorization codes and instructions

For details and the specific CPT/HCPCS codes that require prior authorization for cardiology, providers are directed to UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior.

Prior Authorization

Prior authorization reference and instruction

For details and the CPT codes that require prior authorization, please visit UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources and use the Prior Authorization and Notification tool on the provider portal.

Prior Authorization

Submit prior authorization for outpatient injectable chemotherapy

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting (including intravenous, intravesical and intrathecal) such as J9000–J9999 and specific agents (J0640, J0641, J0642, J1950); submit via the provider portal or call 888‑397‑8129.

Prior Authorization

Prior authorization for devices, DME and implants

Prior authorization is required for selected cochlear and other auditory implants (e.g., 69710, 69711, 69714, 69930), specified glucose monitor codes (A4226, A9278, E0787) and various DME HCPCS codes; some DME requires prior authorization only when retail purchase or cumulative rental cost exceeds $500.

Documentation Required

HCPCS codes requiring prior authorization

HCPCS codes listed for injectable chemotherapy and related services include multiple E‑series codes such as E2300, E2301, E2310, E2311, E2322 and others; these HCPCS entries are enumerated in the policy as requiring prior authorization.

Prior Authorization

Enteral / In-home nutritional therapy prior authorization

Enteral/in‑home nutritional therapy (enteral or via gastrostomy tube) requires prior authorization; listed B‑codes include B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, B4158, B4159, B4160 and B4161.

Prior Authorization

Experimental/Investigational services prior authorization

Services designated as Experimental or Investigational require prior authorization; the policy lists several CPT/HCPCS examples (e.g., 33477, 36514, 64722, 65765, A4638, A6000, E0231, E1831, S0810, S1030, S9988, S9990, S9991).

Prior Authorization

DME and supplies prior authorization

Multiple DME and supply HCPCS K‑ and E‑codes require prior authorization; examples in the list include E2325, E2331, E2351, E2373, E2510 and numerous K‑codes (K0005, K0830, K0850 series).

Prior Authorization

Surgical/procedural prior authorization

Various surgical and procedural CPT codes require prior authorization, including femoroacetabular impingement codes (29914–29916), functional endoscopic sinus codes (31240, 31253–31259, 31267, 31276, 31287–31288) and numerous reconstructive/plastic surgery codes.

Prior Authorization

Injectable chemotherapy prior authorization

Injectable chemotherapy–related HCPCS codes such as E2227, E2228, E2230, E2300, E2301, E2310, E2311 and E2322 are listed across multiple sections as requiring prior authorization.

Prior Authorization

Procedure codes requiring prior authorization (partial list)

Procedure codes listed as requiring prior authorization (partial) include 11980–11983 and 13151–13160 among others; these CPT/HCPCS entries appear in the procedure code lists requiring prior authorization.

Prior Authorization

Procedure codes requiring prior authorization (continued)

Extended procedure code lists requiring prior authorization include numerous reconstructive and surgical CPT codes (e.g., 14020–14061, 14301–14302, 15101, 15200–15274, 15570, 15600, 15734–15738 and many others shown in the document).

Prior Authorization

Procedure codes requiring prior authorization (additional)

Additional procedure codes requiring prior authorization include a broad set of CPT entries shown in the policy (examples: 31599, 31750, 31899, 40500–40799, 43496, 44204, 44700, 45395, 45400 and many others listed).

Prior Authorization

Procedure/lab codes requiring prior authorization

Procedure and laboratory codes requiring prior authorization are listed (examples include 64856, 64892, 80414, 82642, 82670, 84143); the policy also notes that for some codes prior authorization is not required when billed with specified additional codes.

Note

Authorization exceptions

Some codes in the lists include the note '*Prior authorization not required when billed with the following', indicating authorization exceptions for specific code pairings — providers should review the note alongside the code entries.

Documentation Required

Diagnosis codes requiring prior authorization (partial)

The policy lists numerous ICD‑10 diagnosis codes associated with prior authorization requirements (partial listing includes many C43/C44 series codes such as C43.0, C43.10, C43.111 and multiple related codes shown).

Prior Authorization

Prior authorization — home health care

Prior authorization is required for specified home health care services in outpatient settings including the member's home; listed codes include G0156, G0162, G0299, G0300, G0493–G0496 and S9122–S9124.

Prior Authorization

Prior authorization — hearing aid services

Hearing aid services require prior authorization; multiple V‑codes are listed (examples: V5171, V5172, V5181, V5211, V5212, V5230, V5250 and others).

Prior Authorization

Prior authorization — genetic/molecular testing

Genetic and molecular testing performed in an outpatient setting requires prior authorization; listed examples include CPT codes 81120, 81121, 81162, 81163, 81164–81166 and additional molecular testing codes (81208, 81216, 81228, 81229, etc.).

Prior Authorization

Prior authorization — injectable medications

Multiple injectable medications require prior authorization; the policy provides partial lists of J‑ and Q‑codes (examples include J3262, J0791, J1931, J0225, J0256, Q5121, J0490, J0179, J0597, J0585, J0567).

Prior Authorization

Prior authorization required — injectable medications (partial list)

Partial injectable medication lists include many specialty J/Q codes (examples shown: J9217 Luxturna, J1439 IVIG entries, J1306 and others); providers must submit prior authorization requests per payer instructions for these listed agents.

Prior Authorization

Prior authorization required — injectable medications (partial list)

The document lists additional injectable medication HCPCS/CPT codes (examples include J1726, J1729, J2675, J3397, J1437, J1458, J0219, J2796, J2182, J2350, J2354, J0222 and others) that require prior authorization.

Prior Authorization

Additional injectable medication codes

Additional injectable medication entries (examples include J9312 Rituxan Hycela, J9311 Roctavian, J2998 Ryplazim, J2353 Sandostatin LAR, J1449 Rolvedon) are listed with prior authorization requirement.

Prior Authorization

Luxturna (J9217) prior authorization listing

Luxturna (HCPCS J9217) is repeatedly listed in the policy as an injectable therapy that requires prior authorization.

Documentation Required

Prior authorization coding for Supprelin

HCPCS code Q5127 is associated with Supprelin and is listed in the policy as the code referenced for prior authorization for that product.

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 888‑397‑8129 for certain drugs and services; the policy lists specific drugs for which prior authorization is required.

Prior Authorization

Procedures requiring prior authorization

The policy identifies many procedures requiring prior authorization including all inpatient stays and joint replacement (total hip and knee) procedures; example CPT/HCPCS codes for joint replacement and related procedures are listed (e.g., 24360–24363, 27120–27138, 27412, 27446–27487, 29866–29868).

Billing Rule

Orthotics and prosthetics prior authorization threshold

Orthotics and prosthetics L‑codes are subject to prior authorization only when the retail purchase or cumulative rental cost is more than $500; numerous L‑codes are enumerated in the policy.

Prior Authorization

J0897 prior authorization condition

For HCPCS J0897 (Denosumab/Xgeva) the policy states prior authorization is required only for non‑oncology indications.

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy CPT/HCPCS codes listed (e.g., 92507–92633, 97010–97039, 97110–97156) require prior authorization for members age 21 and older per the policy text.

Prior Authorization

L-codes prior authorization listing

A long listing of orthotics/prosthetics L‑codes is provided in the policy; these L‑codes are associated with prior authorization instructions and the portal/phone submission methods.

Prior Authorization

How to obtain prior authorization

Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call 866‑889‑8054 to submit prior authorization requests for listed radiology and other services.

Documentation Required

Provider notification responsibility for advanced imaging

Care providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling; participating physicians requesting advanced outpatient imaging must obtain prior authorization and may submit requests via the provider portal or call 866‑889‑8054.

Prior Authorization

Specific service prior authorization requirements

Prior authorization is required for pain injections and management (e.g., 64490, 64493), private duty nursing (T1002, T1003), potentially unproven services and prostate procedures (codes listed), as indicated in the policy.

Billing Rule

Site of service rules

Site‑of‑service rules: prior authorization is required when requesting certain services in an outpatient hospital setting but is not required if the same service is performed at a participating ambulatory surgery center (ASC) for specified services.

Prior Authorization

Sleep apnea procedures prior authorization

Sleep apnea procedures require prior authorization; example CPT codes listed include 21685, 41599 and 42145.

Prior Authorization

Sleep studies prior authorization

Sleep studies (polysomnography) require prior authorization; the policy specifically lists CPT codes 95805 and 95807.

Prior Authorization

Spinal surgery prior authorization

Spinal surgery requires prior authorization for the listed CPT codes; examples enumerated include 22100, 22101, 22102, 22110, 22206, 22207, 22210, 22510–22514, 22612, 22630 and multiple 630xx series codes.

Documentation Required

Site-of-service outpatient entries

The policy includes site‑of‑service outpatient entries and guidance (example outpatient codes: 64561, 64640) and notes site‑of‑service applicability and related prior authorization instructions.

Key Terms and Definitions

Prior authorization (definition)

DefinitionPrior authorization is the payer's approval process required before certain non‑emergency services or procedures are provided to ensure coverage.

Where usedApplies to specified inpatient and outpatient services and listed CPT/HCPCS codes in this UnitedHealthcare Community Plan policy.

How to requestProviders must submit PA requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by phone (see portal/phone details elsewhere in the policy).

Emergency / urgent care exception

ExceptionEmergency or urgent care services do not require prior authorization.

Provider noteOut‑of‑network providers must request prior authorization for non‑emergent services; emergent/urgent care excluded.

Source linePolicy: 'Prior authorization is not required for emergency or urgent care.'

Cardiology prior authorization resources

ResourceCardiology prior authorization resources are available at UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior.

UseProviders must consult the Cardiology Prior resource for the specific CPT/HCPCS codes and instructions that require prior authorization (e.g., echocardiograms, electrophysiology implants, stress echoes).

Contact methodAccess via UnitedHealthcare Provider Portal (UHCprovider.com) as directed in the policy for detailed cardiology PA requirements.

Cardiology Prior (UHCprovider.com/MDcommunityplan resource)

Resource linkRefer to UHCprovider.com/MDcommunityplan > Prior Authorization and Notification Resources > Cardiology Prior for details and CPT/HCPCS codes requiring prior authorization.

ExamplesDocument references cardiology‑related diagnosis codes (I70.* series) and specific cardiology procedures tied to PA requirements.

ActionProviders should use the referenced Cardiology Prior resource when planning cardiac procedures requiring prior authorization.

Injectable chemotherapy — outpatient oncology

DefinitionInjectable chemotherapy drugs administered in an outpatient setting (intravenous, intravesical, intrathecal) for a cancer diagnosis require prior authorization.

Code examplesIncludes chemotherapy J‑code ranges (J9000‑J9999) and specific J‑codes listed in the policy (e.g., J0640, J0641, J0642, J1950).

SubmissionSubmit PA via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or by the phone number provided for chemotherapy requests as specified in the policy.

Injectable chemotherapy prior authorization list

ListThe policy enumerates multiple HCPCS/J codes associated with injectable chemotherapy that require prior authorization (examples include E2300, E2301, E2310, E2311, E2322 and broad J‑code ranges).

ScopePA applies when these HCPCS/J codes are billed for outpatient chemotherapy administration tied to a cancer diagnosis.

Provider actionUse the Prior Authorization and Notification tool or the chemotherapy‑specific phone number in the document to request authorization for listed injectable chemotherapy drugs.

Prior authorization (overview & submission)

DefinitionPrior authorization is the payer's approval process required before certain non‑emergency services or procedures are provided to ensure coverage.

How to submitRequests should be submitted online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or by phone using the numbers provided in the policy (e.g., 877‑842‑3210 or specialty numbers noted).

Portal namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Experimental / Investigational services (definition)

DefinitionServices designated as Experimental or Investigational in this list require prior authorization.

ExamplesPolicy lists several CPT/HCPCS codes labeled Investigational/Experimental (e.g., 33477, 36514, 64722, 65765, A4638, A6000, E0231, E1831, S0810).

RequirementProviders must obtain prior authorization before providing services identified as Experimental/Investigational in the policy listings.

Prior authorization exception (billing combinations)

ExceptionSome lines in the policy note that prior authorization is not required when certain codes are billed together (authorization exceptions are indicated by '*Prior authorization not required when billed with the following').

ImplicationProviders should check the exception notes on specific code lines to determine if PA is waived when codes are billed in combination.

ReferenceSee policy code lines where the exception phrase appears (e.g., chunk 118).

Gender dysphoria treatment (context)

ContextGender dysphoria treatment appears as a contextual grouping adjacent to listed procedural codes in the policy, indicating those procedures may be subject to prior authorization when applicable.

ExamplesNumerous reconstructive/plastic surgery CPT codes (e.g., 14020, 14021, 14301, 15101, 15200, 15570) are listed near the Gender dysphoria treatment block.

ActionProviders should verify PA requirements for specific reconstructive/plastic surgery codes used in gender dysphoria care per the listed CPT codes and instructions in the policy.

Genetic / molecular testing prior authorization

DefinitionGenetic and molecular testing (including BRCA gene testing) performed in an outpatient setting requires prior authorization.

Code examplesPolicy lists molecular/genetic CPT codes such as 81120, 81121, 81162, 81163, 81164–81166 and multiple 812/813 series codes that require PA.

Provider actionObtain prior authorization before ordering genetic/molecular testing listed in the policy for outpatient settings.

Home health prior authorization

ScopeHome health services provided in outpatient settings, including services delivered in the member's home, require prior authorization.

CodesExamples include G0156, G0162, G0299, G0300, G0493–G0496 and S9122–S9124 as listed in the policy.

ConditionPA applies when home health services are provided in outpatient settings per the policy language.

Injectable medications — prior authorization

DefinitionMultiple injectable medications (J‑, Q‑ and other HCPCS codes) listed in the policy require prior authorization.

ExamplesSample entries include J3262 (Actemra), J0791 (Adakveo), J1931 (Aldurazyme), Q5121 (Avsola), J9217 (Luxturna) and many other J/Q codes shown.

How to obtainSubmit PA online via the Prior Authorization and Notification tool or by the telephone number(s) listed for drug submissions (policy provides portals and phone contacts for specific drug groups).

Supprelin

ProductSupprelin (HCPCS Q5127) is listed in the policy with Q5127 referenced repeatedly for prior authorization.

CodeHCPCS code Q5127 is the policy reference for Supprelin prior authorization entries.

NotePolicy contains multiple Q5127 entries indicating PA applicability for Supprelin; providers should follow the general PA submission instructions in the document.

Review at Launch policy

Policy'Review at Launch for New to Market Medications' is referenced for up‑to‑date info on newly approved drugs; pre‑determination is recommended for drugs on that list.

Where to findAvailable at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.

Related actionProviders should consult the Review at Launch policy for recently FDA‑approved medications and consider pre‑determination where recommended.

Provider Portal prior auth submission

Primary methodSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Alternate methodPhone numbers are provided for specific request types (general portal phone 877‑842‑3210; specialty numbers such as 866‑889‑8054 or 888‑397‑8129 appear for imaging/chemotherapy/drug groups in the policy).

Portal namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

J0897 prior authorization condition

ConditionFor J0897, prior authorization is required only for non‑oncology indications (oncology uses do not require PA per policy note).

CodeJ0897 (Denosumab) — PA condition explicitly stated in multiple policy lines.

ReferenceSee policy notes for J0897 and related 'Review at Launch' cross‑reference for drug updates.

Outpatient therapy PA age rule

RuleOutpatient therapy codes listed require prior authorization for members age 21 and older.

Example codesIncludes CPT codes such as 92507–92526, 97010–97039, 97110, 97112–97116, 97124, 97129–97156 as listed in the policy.

Source notePolicy fragment: 'Outpatient therapy, Additional information = Prior authorization required for members ages 21 and.' (text incomplete in source but indicates 21+).

Prior Authorization and Notification tool

Tool namePrior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com).

Use caseUsed to submit prior authorization and notification requests for advanced imaging, drugs, DME, and other services listed in the policy.

Portal accessGo to UHCprovider.com, click Sign In, then select the Prior Authorization and Notification tile on the provider portal dashboard.

Advanced radiation therapy

DefinitionAdvanced radiation therapy categories listed include IMRT/IGRT, SRS/SBRT and proton beam therapies which require prior authorization for specified diagnosis ranges.

Example codesExamples: IMRT/SRS codes and proton beam CPTs such as 77385, 77401, 77520 series are listed for PA consideration.

ConditionSome standard radiation therapy codes require PA only when billed with specified cancer diagnosis codes (see policy for diagnostic code ranges).

Site of service (SOS)

DefinitionSite‑of‑service (SOS) guidance indicates PA may be required when services are performed in an outpatient hospital setting but may not be required when performed at a participating ambulatory surgery center for specified services.

ExamplesPolicy lists SOS entries and associated codes (e.g., 64561, 64640) and notes site‑specific PA implications.

Provider responsibilityCare providers ordering advanced outpatient imaging procedures are responsible for providing notification prior to scheduling per SOS rules in the policy.

OpenPayer

Prior authorization requirements for Maryland Medicaid

Services and Codes Requiring Prior Authorization

Code Lists and Special Coding Rules

How Providers Request Authorization and What to Do

Key Terms and Definitions

Document History