CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for UnitedHealthcare Mid-Atlantic Health Plans

Defines prior authorization requirements, submission methods, and examples of CPT/HCPCS codes that require prior authorization for participating UnitedHealthcare Mid-Atlantic Health Plans providers; applies to inpatient and outpatient services and facilities/providers in the Mid-Atlantic region.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for UnitedHealthcare Mid-Atlantic Health Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat; verify approval is on file before performing elective services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online, Chatsubmission methods for prior authorization

Emergency/urgentprior authorization NOT required

Manyexample codes shown

Multipleinjectable oncology/supportive care drugs

888-397-8129

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phone for prior auth

Coverage and Prior Authorization Criteria

General prior authorization criteria

General coverage stance and prior authorization rules for services included in this list:

Prior authorization is required for elective services; facilities must verify coverage approval is on file before performing a service; payment may be denied if authorization is not obtained.

Prior authorization is not required for emergency or urgent care.

Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services when the member's plan includes out-of-network benefits.

Submit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat on the Contact us page.

Site-of-service will be reviewed as part of prior authorization for many listed codes (exceptions for AK, MA, PR, RI, TX, UT, VI and WI are noted elsewhere).

BRCA and genetic testing

Genetic testing coverage conditions:

Prior authorization is required for BRCA (BRCA1 and BRCA2) genetic testing before DNA sequencing is performed.

Genetic counseling is required prior to testing by a qualified care provider and the laboratory must notify UnitedHealthcare when tests are performed.

Listed CPT/HCPCS and proprietary codes for BRCA and related genetic tests (examples in the policy) must follow the authorization process; refer to the laboratory notification requirement in the policy.

Oncology/supportive care prior authorization requirements

Prior authorization requirements for oncology and supportive care:

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis (including J9000-J9999 and listed J/Q codes).

Prior authorization is required for colony-stimulating factor drugs administered in an outpatient setting for a cancer diagnosis (examples: J1449, J1442, J2506 and listed Q-codes/biosimilars).

Also note:

Some codes (e.g., J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) require prior authorization even for non-oncology diagnoses.
Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129.

Procedure and diagnosis code prior authorization listings

Procedure and diagnosis code listings:

Many specific CPT/HCPCS procedure codes (examples: breast reconstruction codes such as 15771, 19300, 19325, 19357, L8600) are identified as requiring prior authorization.

The document enumerates numerous ICD-10 diagnosis codes for which prior authorization is not required when billed with certain procedures (detailed code lists are in the policy).

Refer to the full policy sections for the exact mappings of CPT/HCPCS codes to diagnosis codes and any exceptions — the chunks cited contain partial enumerations.

Coverage requirements (examples)

Examples of coverage-related requirements and prior authorization notes in this excerpt.

Cartilage implant procedures require prior authorization (examples: 27412, 27415, 27416, 29866).

Inpatient video EEG (cerebral seizure monitoring) requires prior authorization for inpatient services (examples: 95700, 95715, 95716, 95718).

Injectable chemotherapy drugs administered outpatient require prior authorization (examples include J9000-J9999 and specified J/Q codes).

Clinical trials–related services require prior authorization (examples: S9988, S9990, S9991).

Certain congenital heart disease–related services require advance notification; contact the Optum VAD Case Management Team as directed in the policy.

Partial coverage criteria (codes and PA requirements)

Coverage/authorization stance for services and codes listed in this section (partial):

Continuous glucose monitors and related supplies (listed HCPCS codes such as A4226, A4238, A4239, A9276–A9278, E0787, E2102/E2103) require prior authorization when billed for type 2 diabetes.

Cosmetic and reconstructive procedures require prior authorization in all states (examples of CPT codes are listed in the policy: 11960, 11970, 14020, 14021, etc.).

Some CPT procedures may be exempt from prior authorization when billed with specified diagnosis codes (the policy lists many ICD-10 C50*/D05* codes that are examples of such exemptions).

Prior authorization/notification notes

Operational prior authorization/notification notes present in the excerpt:

Certain DME and orthotics/prosthetics items require prior authorization only when listed with a retail purchase or cumulative rental cost above the documented threshold (commonly $1,000).

For ESRD dialysis notification/prior authorization, providers should connect via 24/7 chat on the Contact us page per the policy guidance.

Prior authorization requests for many services should be submitted online via the Provider Portal; some categories (e.g., therapy services) require fax submission per the Rehabilitation Services process.

Prior authorization requirement (partial)

Partial code list indicating prior authorization requirement

Functional endoscopic sinus surgery (FESS) and related sinus/foot/ankle procedure codes (examples: 31254–31298 and 28296–28299) are repeatedly listed as requiring prior authorization (see FESS sections for full lists).

Authorization requirement for FESS procedures

Prior authorization requirement for listed FESS codes

Prior authorization required for functional endoscopic sinus surgery (FESS) CPT/HCPCS codes: 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31298 (policy lists these codes and notes 'required').

Prior authorization code list

Prior authorization requirement for listed CPT/HCPCS codes

Prior authorization is required for the CPT/HCPCS codes listed across these sections (examples include 31240, 31253, 31254–31259, 31267, 31276, 31287; and foot/ankle codes 28292–28299).

This excerpt is informational and focuses on code listings and authorization status; clinical coverage criteria or step-therapy rules are not specified in these chunks. Refer to the full policy for clinical criteria.

Items requiring prior authorization (partial list)

Prior authorization required for listed procedures, gender dysphoria treatments, injectable medications, and some home health and hysterectomy services.

Gender dysphoria treatments and a long list of specified surgical CPT codes require prior authorization (see policy for full code list and whether requirement applies regardless of diagnosis).

Certain inpatient and outpatient hysterectomy procedures require prior authorization as listed in the policy (codes and distinctions provided in the full section).

Injectable medications across multiple therapy groups require prior authorization; pharmacy/provider notification and specialty pharmacy processes are described in the policy (including the 3-day provider contact if drug PA requirements are not met).

Home health (non-nutritional in-home nursing services) may require prior authorization (T1000/T1002/T1003 examples are listed where applicable).

MRgFUS conditioned coverage

MRgFUS coverage conditions for uterine fibroid

MR-guided focused ultrasound (MRgFUS) to treat uterine fibroid is a covered service for certain benefit plans but is subject to prior authorization and the plan's terms and conditions.

Prior to authorization, the physician/facility must confirm the member's benefit coverage and the facility must be contracted with UnitedHealthcare.

A member must provide written consent acknowledging limited published evidence of safety/effectiveness and must agree in writing not to hold UnitedHealthcare responsible if dissatisfied with results.

Physician and facility must demonstrate experience and expertise performing MRgFUS as part of the authorization considerations.

Orthognathic surgery prior auth criteria

Orthognathic surgery

Prior authorization is required for listed orthognathic surgery CPT codes used to treat maxillofacial functional impairment.

Examples of orthognathic CPT codes included in the list: 21050, 21060, 21121, 21123, 21125, 21127, 21141–21147, 21150–21155 (see policy for full enumeration).

Air transport prior auth

Non-emergency air transport

Prior authorization is required for non-emergency air ambulance transport codes (examples: A0430, A0431, A0435, A0436).

Prior authorization criteria (summary)

Prior authorization requirements and limitations for listed services:

Orthognathic surgery: prior authorization required for the listed CPT/HCPCS codes for treatment of maxillofacial functional impairment (see Orthognathic section).

Out-of-network services: prior authorization required when a network provider directs a member to an out-of-network provider and the member's plan includes out-of-network benefits; members may incur increased costs.

Pain management and injection services require prior authorization (policy lists relevant injection and pain management CPT/HCPCS codes).

Outpatient physical, occupational and speech therapy services require prior authorization; the initial referral is valid for up to 8 visits per condition within 6 months; additional visits require preauthorization; therapy prior authorization requests cannot be submitted online and must be faxed per the Rehabilitation Services process.

Orthotics/prosthetics: prior authorization required only for codes listed with a retail purchase or cumulative rental cost greater than $1,000; prosthetic and orthotic L-code examples and thresholds are provided in the policy.

Prior authorization coverage criteria (partial excerpt)

Prior authorization requirements and conditional rules reflected in the code lists and notes below.

Many radiation therapy and proton beam therapy CPT/HCPCS codes require prior authorization (examples include IGRT 77014, 77385/77386 with G6015/G6016, proton beam codes 77520/77522/77523).

Standard Radiation Therapy (2D/3D) requires prior authorization only when billed with specified cancer diagnosis code ranges (e.g., C34.00–C34.92, C50.011–C50.929, C61, C79.51–C79.52, C84.7A, D05.00–D05.92).

Certain dermatologic/office-based procedures require prior authorization when performed in an outpatient hospital setting; site-of-service rules affect authorization requirements.

PA coverage criteria (section)

Prior authorization criteria and stances for procedures in this document:

Surgical sleep apnea procedures (e.g., palatopharyngoplasty/uvulopalatoplasty, tonsillectomy/adenoidectomy and related surgeries) require prior authorization for inpatient and outpatient settings; this does not apply to sleep studies themselves in the home setting.

Facility-based laboratory polysomnography (sleep studies) require prior authorization; home sleep studies are excluded.

Spinal cord stimulator implantation and associated device HCPCS codes require prior authorization for all states; site-of-service will be reviewed and jurisdictional exceptions are noted in the policy.

Site-of-service rule

Prior authorization is not required when certain procedures are performed in an office setting (office-based program exceptions apply in specified jurisdictions).

Prior authorization criteria and exceptions

Prior authorization requirements and notable exceptions

Prior authorization is required for numerous listed CPT/HCPCS procedure codes (including many spine procedures and device implantations) as enumerated in the policy code lists.

Site-of-service will be reviewed as part of prior authorization for listed codes except in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin.

Care providers must request prior authorization for transplant or transplant-related services prior to pre-treatment or evaluation (see transplant section for related CPT examples).

Exceptions

Certain combinations of procedure codes and specific incontinence diagnosis ICD-10 codes may not require prior authorization (specific ICD-10 codes are listed in the policy).

Prior authorization timing requirement

Administrative requirement

Care providers must request prior authorization for transplant or transplant-related services before pre-treatment or evaluation; example related visit CPT code: 99205 is referenced in the transplant evaluation context.

Providers must follow the submission methods and timelines in the policy (online portal, phone numbers, or specialty pharmacy/transaction tiles where applicable) to request predetermination or authorization prior to services being performed.

CPT/HCPCS/ICD-10 Code Listings

Arthroscopy example codesCPTCovered

29826	arthroscopy code listed in examples
29843	arthroscopy code listed in examples
29871	arthroscopy code listed in examples

Arthroplasty and related procedure codesCPTCovered

23470	arthroplasty-related code listed
25444	upper extremity/orthopedic code listed
27120	hip arthroplasty code listed

Bone growth stimulator codesCPTCovered

20974	bone growth stimulator
20975	bone growth stimulator
20979	bone growth stimulator

Injectable cancer supportive care drugsHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1454	Palonosetron/fosnetupitant (Akynzeo)
J0185	Aprepitant (Cinvanti)
J1453	Fosaprepitant (Emend)
J1456	(listed anti-emetic)
J1627	Granisetron extended release (Sustol)
J0897	Denosumab (Prolia/Xgeva)
J0885	Epoetin alfa
J1442	Filgrastim (Neupogen)
J2506	Pegfilgrastim (Neulasta)

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Breast reconstruction CPT/HCPCS codesCPT/HCPCSCovered

15771	Breast reconstruction code
19300	Breast reconstruction/mastopexy
19316	Breast reconstruction
19318	Breast reconstruction
19325	Breast reconstruction
19328	Breast reconstruction
19330	Breast reconstruction
19340	Breast reconstruction
19342	Breast reconstruction
19350	Breast reconstruction

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Sample ICD-10-CM codes referencedICD-10

I70.761	ICD-10-CM code listed in prior auth section
I70.762	ICD-10-CM code listed in prior auth section
M86.051	ICD-10-CM code listed in prior auth section (osteomyelitis variants)
M86.172	ICD-10-CM code listed in prior auth section

Sample CPT codes referencedCPT

27412	CPT code listed for cartilage implant
27415	CPT code listed for cartilage implant
27416	CPT code listed for cartilage implant
29866	CPT code listed for cartilage implant
95700	CPT code for inpatient video EEG
95715	CPT code for inpatient video EEG
95716	CPT code for inpatient video EEG
95718	CPT code for inpatient video EEG

Clinical trials HCPCS codesHCPCS

S9988	HCPCS code for clinical trial-related service
S9990	HCPCS code for clinical trial-related service
S9991	HCPCS code for clinical trial-related service

Diagnosis codes exempting prior authorization for some CPTsICD-10Covered

C43.0	Malignant melanoma of lip (example ICD-10 listed)
C44.01	Basal cell carcinoma of skin of lip (example ICD-10 listed)
C44.310	Squamous cell carcinoma of skin of eyelid (example ICD-10 listed)

ICD-10 code fragmentsICD-10

C44.500	ICD-10 (code fragment as listed)
C44.501	ICD-10 (code fragment as listed)
C44.509	ICD-10 (code fragment as listed)
C44.510	ICD-10 (code fragment as listed)
C44.511	ICD-10 (code fragment as listed)
C44.519	ICD-10 (code fragment as listed)
C44.520	ICD-10 (code fragment as listed)
C44.521	ICD-10 (code fragment as listed)
C44.529	ICD-10 (code fragment as listed)
C44.590	ICD-10 (code fragment as listed)

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Dialysis CPT/HCPCSmixedCovered

90935	Hemodialysis
90937	Hemodialysis
90945	Peritoneal dialysis
90947	Peritoneal dialysis
90999	Unlisted dialysis service (outpatient)
J0606	Drug/service code referenced with outpatient dialysis
S9335	Home dialysis/relevant service code
S9339	Home dialysis/relevant service code

FESS CPT codesCPTCovered

31276	Endoscopic sinus surgery code referenced for prior authorization
31287	Endoscopic sinus surgery code referenced for prior authorization
31288	Endoscopic sinus surgery code referenced for prior authorization
31298	Endoscopic sinus surgery code referenced for prior authorization

Dialysis servicesmixedCovered

Non-routine dialysis	Textual reference indicating dialysis services may require prior authorization
Renal dialysis	Textual reference indicating dialysis services may require prior authorization

FESS CPT/HCPCS codesCPT

31254	Endoscopic sinus procedure (listed in document)
31255	Endoscopic sinus procedure (listed in document)
31256	Endoscopic sinus procedure (listed in document)
31257	Endoscopic sinus procedure (listed in document)
31259	Endoscopic sinus procedure (listed in document)
31267	Endoscopic sinus procedure (listed in document)
31276	Endoscopic sinus procedure (listed in document)
31287	Endoscopic sinus procedure (listed in document)
31288	Endoscopic sinus procedure (listed in document)
31298	Endoscopic sinus procedure (listed in document)

Functional endoscopic sinus codesCPTCovered

31254	Functional endoscopic sinus procedure
31255	Functional endoscopic sinus procedure
31256	Functional endoscopic sinus procedure
31257	Functional endoscopic sinus procedure

Foot/ankle codesCPTCovered

28296	Foot/ankle procedure (listed in document)
28297	Foot/ankle procedure (listed in document)
28298	Foot/ankle procedure (listed in document)
28299	Foot/ankle procedure (listed in document)
28292	Foot/ankle procedure (listed in document)

Surgical and procedure CPT codes (examples listed in section)CPTCovered

28291
28292
28296
28297
28298
28299
28289
14000
14001
14041

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Drug/J-code and HCPCS entries (examples)HCPCS | CPTCovered

G0027
J9218
J0896	anemia infusion
J1437
J1426
J0222
J0223
J1306	collagenase (example drug)
J0775	complement inhibitors - ophthalmologic use
J0567	enzyme replacement therapy

Selected HCPCS/J codes (examples from excerpt)HCPCS

J2781	example injectable/drug code referenced
J2782	example injectable/drug code referenced
J0224	endocrine injectable code referenced
J0180	infused drug code referenced

Injectable and immune product codesHCPCS

J7170	injectable medication code listed
J7193	injectable medication code listed
J1551	immune globulin code listed
J1602	immune modulator / medication code listed

Special-case / temporary codesHCPCS

J1305	codes listed for rare conditions / RSV prophylaxis reference
J3590	unclassified/temporary code; prior auth only for specific drugs

Orthognathic surgery codes (partial list shown)CPTCovered

A0436	Orthognathic surgery / transport of maxillofacial functional impairment
21050	Orthognathic surgery
21121	Orthognathic surgery

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

L0220	Orthotics codes (example)
L5010	Prosthetics codes (example)

Therapy and injection CPT codes (examples)CPTCovered

62320

Epidural injection codes (example)

Radiation therapy / Proton beam codesCPT | HCPCS | mixedCovered

77014	IGRT
77385	Radiation therapy planning/related (also listed for proton beam)
77386	Radiation therapy planning/related
G6001	Radiation therapy - listed
G6015	Radiation therapy - listed
G6016	Radiation therapy - listed
77520	Proton beam therapy
77522	Proton beam therapy
77523	Proton beam therapy

Rhinoplasty / Sinuplasty codesCPTCovered

30400	Rhinoplasty
30410	Rhinoplasty
30420	Rhinoplasty
31295	Sinuplasty
31296	Sinuplasty
31297	Sinuplasty

Radiology CT codes (examples)CPTCovered

70450	CT head/brain
70460	CT orbit/sinus
70470	CT neck
70480	CT chest
70481	CT chest with contrast
70486	CT colonography

Representative CPT procedure codes requiring prior authorizationCPTCovered

20930	Listed mapping to procedure codes in document
20931	Listed mapping to procedure codes in document
20939	Listed mapping to procedure codes in document
22100	Listed mapping to procedure codes in document
22513	Spinal surgery/procedure code shown later in list
63001	Spinal surgery/procedure code shown later in list

HCPCS / device codesHCPCSCovered

E0747	Bone-growth stimulator
E0748	Bone-growth stimulator
E0749	Bone-growth stimulator
E0760	Stimulator device
64590	Neurostimulation (noted with *)

ICD-10 diagnosis codes referencedICD-10

N32.81	Neuropathic bladder
N39.3	Stress incontinence
R15.0	Incomplete defecation

Referenced CPT codes for transplant evaluation/proceduresCPT

99205	Office/outpatient visit for new patient (noted repeatedly in relation to pre-treatment/evaluation)
33944	Heart transplant-related procedure code (appears in heart/transplant context)

DME cost threshold

Threshold value$1,000 retail purchase or cumulative rental cost

Provider Submission Methods and Required Actions

Prior Authorization

Submission methods and general authorization rules

This list contains prior authorization requirements for participating UnitedHealthcare Mid-Atlantic Health Plans health care professionals providing inpatient and outpatient services. Please submit your requests in one of the following ways: Online: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID and password and select the Prior Authorization and Notification tab. If you don't have a One Healthcare ID, visit UHCprovider.com/access. Chat: Connect through chat 24/7 using the Contact us page. For telephone assistance related to prior authorization submission or questions, call 888-397-8129. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services when member benefits require it. Prior authorization is required for elective services — the ordering physician is responsible for obtaining relevant prior authorization; facilities must verify approval is on file before performing a service. Services rendered without required prior authorization may be denied. Final coverage and payment determinations are based on the member's plan, eligibility, benefits, the provider contract and applicable state law.

Prior authorization not required for emergency or urgent care
Providers: use the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal or chat via Contact us page; phone support: 888-397-8129
Facilities must verify authorization is on file before performing a service

Key Definitions and Terms

Prior authorization overview

DefinitionPrior authorization is the requirement to obtain approval from UnitedHealthcare before performing elective services; failure to obtain may result in payment denial.

Who must obtainPhysician is responsible to obtain prior authorization; facilities must verify coverage approval is on file before performing a service.

ExceptionsPrior authorization is not required for emergency or urgent care; out-of-network providers must request prior authorization for all procedures/services.

Genetic counseling attestation for BRCA and genetic testing

RequirementGenetic counseling is required prior to BRCA and other specified genetic testing; the laboratory must notify UnitedHealthcare

Tests referenced

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for UnitedHealthcare Mid-Atlantic Health Plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2025

Next Review DateN/A

SourceLink

On This Page

Prior authorization is required when the same service is requested in an outpatient hospital setting.

Applies toOrthotics and prosthetics codes and certain DME (power mobility and listed HCPCS E-/A- codes)

Action when exceededPrior authorization required when retail purchase or cumulative rental cost exceeds $1,000

Review at Launch consideration

RecommendationPredetermination (preauthorization) is highly recommended for medications on the Review at Launch (new-to-market) list

Where to checkReview at Launch for New to Market Medications policy and the Review at Launch Medication List

RationaleEnsures up-to-date coverage and authorization guidance for newly FDA-approved drugs

Authorization threshold for retail purchase or cumulative rental cost

Authorization threshold$1,000 retail purchase or cumulative rental cost triggers prior authorization

Applies toOrthotics and prosthetics codes listed in the policy (specified L-codes) and certain DME items

Reference examplesOrthotics L1755 and various L2xxx codes; multiple prosthetic L5xxx codes referenced in policy

Initial therapy visits authorized per referral

Initial authorization per referralUp to 8 visits per condition within 6 months from the referral date

If visits not specifiedReferral valid for one visit only

Additional visitsAny visits beyond the initial 8 require preauthorization

Submission methodTherapy prior authorization requests cannot be submitted online; fax to Clinical Care Coordination at 888-831-5080 using the Rehabilitation Services Extension Request Form

Standard Radiation Therapy (2D/3D) prior auth conditional on diagnosis

Condition for prior authorizationStandard Radiation Therapy (2D/3D) requires prior authorization only when billed with specified cancer diagnosis code ranges

Diagnosis code rangesC34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A; D05.00–D05.92

How to submitUse the Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (select Radiology/Cardiology/Oncology/Radiation Therapy) to route authorization requests

Prior Authorization

Arthroscopy prior authorization and site-of-service review

Arthroscopy procedures require prior authorization for all states. Site-of-service review is performed as part of the prior authorization process for many arthroscopy and related procedure codes (site-of-service review exceptions apply in: Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin).

Prior authorization required for arthroscopy procedure codes
Site-of-service review for specified arthroscopy codes (see policy code lists)

Prior Authorization

BRCA genetic testing prior authorization

Genetic testing for BRCA1/BRCA2 and related hereditary breast/ovarian cancer panels requires prior authorization before DNA sequencing is performed. Genetic counseling is required prior to testing by a qualified care provider to review hereditary risk and implications. See Oncology Prior Authorization resources for required supportive documentation and test-specific CPT/HCPCS/U codes.

Prior authorization required before BRCA sequencing
Genetic counseling required prior to testing
Approved/required CPT/HCPCS and proprietary U-codes (e.g., many 8xxxx and 0xxxxU codes) — submit supporting documentation and laboratory information

Prior Authorization

Submit prior authorization for injectable oncology/supportive care drugs and listed codes

Submit prior authorization for injectable oncology and cancer-supportive care drugs administered in outpatient settings (IV, intravesical, intrathecal, subcutaneous or intramuscular) including colony-stimulating factors. Many J- and Q-codes require authorization; some codes also require authorization for non-oncology diagnoses (see code list). For these medications, submit online via the Provider Portal Prior Authorization and Notification tool or call 888-397-8129.

Injectable chemotherapy drugs (J9000-J9999) and related J/Q codes require prior authorization for outpatient administration for cancer diagnoses
Specific supportive care codes requiring prior auth include: J1447, J1448, J2820, J1447 (Trilaciclib/Cosela™), and Q-codes such as Q5108, Q5111, Q5120, Q5122 (pegfilgrastim biosimilars)
Certain codes (J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125) may also require prior authorization for non-oncology diagnoses

Prior Authorization

Procedure codes requiring prior authorization (breast reconstruction, arthroscopy, others)

UnitedHealthcare requires prior authorization for many procedures including breast reconstruction, cosmetic/reconstructive procedures, orthognathic surgery, FESS and other sinus procedures, selected arthroscopy and spinal procedures, and many inpatient/outpatient surgeries. Below are highlights of procedure categories, representative CPT codes and operational notes — always verify member coverage and submit the required supporting clinical documentation with the authorization request.

Breast reconstruction: prior authorization required for many CPT codes including 15771, 19300, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19396 and related HCPCS L8600
Cosmetic and reconstructive procedures: prior authorization required for cosmetic/reconstructive CPT codes in all states (examples: 11960, 11970, 11971, 14020*, 14021*, 14061*, 14302, 15570, 15572, 15574, 15730, 15733, 15740, 15756, 15757, 15758, 15734, 15738, 15750)
Functional endoscopic sinus surgery (FESS) and related codes: prior authorization required for multiple CPT codes including 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31298 and 28297-28299 series (see full policy lists)
Orthognathic surgery: prior authorization required for a broad set of CPT codes (21050, 21060, 21121, 21123, 21125, 21127, 21141–21147, 21150–21155, 21159–21160, 21188, 21193–21199, 21206–21210, 21215, 21240–21249, 21255, 21296, 21299 and related codes)
Spinal and implantable device procedures (including spinal cord stimulators) require prior authorization; examples include neurostimulation/implant codes 63650, 63655, 63662, 63664 and associated device L-codes (L86xx series)
Site-of-service review: for selected ambulatory procedures (including many arthroscopy, spinal, sleep surgery and implant codes) UnitedHealthcare will review the requested site of service and may require outpatient hospital versus office setting justification; exceptions for certain states are noted above

Prior Authorization

How to submit prior authorization requests

How to submit prior authorization requests: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID and choose the appropriate product type (Commercial, Radiology/Cardiology/Oncology/Radiation Therapy workflows may route to partner sites). For therapy-related services (physical, occupational, speech), prior authorization requests cannot be submitted online; fax these requests to Clinical Care Coordination at 888-831-5080 using the Rehabilitation Services Extension Request Form. For many specialty injectable medications and biologics, online submission is supported; questions may be directed to Optum at 888-397-8129. For ESRD dialysis notification/prior authorization, use the chat Contact us page to connect 24/7.

Online: Prior Authorization and Notification tool on UnitedHealthcare Provider Portal (UHCprovider.com)
Therapy services (PT/OT/ST): fax prior authorization requests to Clinical Care Coordination — fax: 888-831-5080 (use Rehabilitation Services Extension Request Form)
Specialty drug/infusion questions: Optum support 888-397-8129
ESRD dialysis notification/prior authorization: connect via Contact us chat 24/7

Prior Authorization

Cosmetic and reconstructive CPT codes and prior authorization

Cosmetic and reconstructive CPT/HCPCS codes require prior authorization in all states. This includes procedures to change or improve appearance as well as many gender dysphoria–related surgical codes when prior authorization requirements apply. Providers must submit clinical documentation demonstrating medical necessity where applicable.

Cosmetic/reconstructive example CPT codes that require prior authorization: 11960, 11970, 11971, 14020*, 14021*, 14061*, 14302, 15570, 15572, 15574, 15730, 15733, 15734, 15738, 15740, 15750, 15756, 15757, 15758, 19303, 19326 series where applicable
Gender dysphoria treatments/surgeries: many CPT codes require prior authorization (see policy lists); authorization required regardless of diagnosis for specified codes and required when submitted with diagnosis codes F64.x or Z87.890 for others

Prior Authorization

K-code DME/orthotics references and DME prior authorization notes

Durable medical equipment (DME), orthotics and prosthetics: prior authorization is required for many DME/orthotics/prosthetic codes based on retail purchase price thresholds or cumulative rental cost (commonly > $1,000) and for specific K- and L-codes. Some power mobility and complex DME items require prior authorization. Refer to the code lists and required documentation for retail purchase/rental thresholds and mapping from CPT to HCPCS L/K codes.

DME examples requiring prior authorization: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297, E0300, E0302, E0304, E0328, E0329, E0466, E0471, E0483, E0745, E0764, E0766, E0770, E0784, E0984, E0986, E1002–E1006
K-code references: K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877 (see DME code lists)
Power mobility and complex DME: prior authorization required (many E10xx and E07xx codes) and some items subject to $1,000 retail/rental thresholds

Prior Authorization

ESRD dialysis prior authorization notes and contact method

Dialysis and ESRD: advance notification or prior authorization is required for end-stage renal disease (ESRD) dialysis services. For notification/prior authorization, connect via the Contact us chat 24/7 on the UnitedHealthcare website. Non-routine dialysis services may be subject to additional authorization requirements.

Advance notification/prior authorization required for ESRD dialysis services
Use Contact us chat 24/7 for dialysis notification/prior authorization
Non-routine dialysis services require prior authorization and may need additional documentation

Prior Authorization

FESS and related surgical codes

Functional endoscopic sinus surgery (FESS), sinuplasty and other sinus procedures require prior authorization for many CPT codes. Representative CPT codes requiring authorization include 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31298 and related 28297–28299 series. Providers must submit clinical documentation to support medical necessity.

FESS / sinus procedure example codes requiring prior authorization: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31298
Some related nasal functional impairment / sinuplasty codes (31295–31297) and sinuplasty codes 31295–31297 may require prior authorization
Submit operative reports, imaging and clinical notes to support urgency/necessity and site-of-service selection

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery requires prior authorization. A broad list of CPT codes for corrective maxillofacial surgery requires authorization (examples: 21050, 21060, 21121, 21123, 21125, 21127, 21141–21147, 21150–21155, 21159–21160, 21188, 21193–21199, 21206–21210, 21215, 21240–21249, 21255, 21296, 21299). Provide preoperative evaluation, imaging and documentation of functional impairment when requesting authorization.

Prior authorization required for orthognathic surgery CPT codes (see code list)
Submit pre-op evaluation, imaging, dental/orthodontic records and documentation of functional impairment

Prior Authorization

Prior authorization for orthotics and prior authorization for prosthetics

Orthotics and prosthetics: prior authorization is required for many orthotics/prosthetic codes when listed with a retail purchase price or cumulative rental cost above the policy threshold (commonly > $1,000). Representative orthotics L-codes include L0220, L0484, L0486, L0636, L0638, L1640, L1680, L1685, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034–L2038 and many others. Representative prosthetic L-codes mapped from CPT examples are listed in the policy (see Prosthetics code mapping and thresholds).

Orthotics prior authorization required for L-codes listed with retail purchase/cumulative rental thresholds (examples: L0220, L0484, L0486, L0636, L0638, L1640, L1680, L1700, L1710, L1720, L1755, L1844, L1846, L2005, L2020, L2034–L2038)
Prosthetics prior authorization required when retail purchase or cumulative rental cost exceeds $1,000; many prosthetic items map from CPT to L-codes (see policy lists such as L50xx–L60xx series)
Provide itemized cost, supplier quotes, and clinical justification with submission

Prior Authorization

Selected procedure codes and PA notes

Selected procedure codes and PA operational notes: many specific CPT/HCPCS codes across specialties require prior authorization; the policy lists code series and operational instructions (site-of-service review, state exceptions, submission routing). Examples and notes include: chemotherapy/infusion J- and Q-codes (authorization via Provider Portal), implantable devices and neurostimulator device L-codes (authorization and device tracking required), sleep apnea surgical procedures and sleep studies (surgical procedures require authorization; home sleep studies excluded), clinical trial codes (S9988–S9991), and transplant/pre-treatment evaluation codes (prior authorization required before pre-treatment or evaluation). Always include supporting documentation (operative reports, imaging, pathology, prior conservative management) with the authorization request.

Chemotherapy injectable codes: J9000–J9999 and specified J/Q codes — submit online via Provider Portal
Spinal cord stimulator/implant codes (63650, 63655, 63662, 63664) and associated L86xx device codes require prior authorization and site-of-service review
Sleep apnea surgical procedures require prior authorization (surgical codes and site-of-service review); laboratory polysomnography (95805–95811, 95807–95810) requires authorization for lab-based studies (home studies excluded)
Transplant services: prior authorization required for transplant evaluation, pre-treatment and transplant-related services (examples: bone marrow harvest, 38240, 38241; request authorization before evaluation)

BRCA 1/2 testing codes and associated sequencing codes (e.g., 81162, 81349, 81425 and others listed)

Prior authorization timingPrior authorization is required for BRCA testing before DNA sequencing is performed

Prior authorization for oncology/supportive care injectables

DefinitionPrior authorization is the approval process providers must use to obtain coverage confirmation from UnitedHealthcare before performing certain procedures or administering specified outpatient injectable chemotherapy or supportive care drugs.

Applies toInjectable chemotherapy and colony-stimulating factor drugs administered in an outpatient setting for cancer diagnoses (codes listed in policy)

Submission methodsSubmit via Prior Authorization and Notification tool on Provider Portal or call 888-397-8129; commercial plan providers may submit predetermination requests via the Provider Portal Transactions tile for specialty drugs

Clinical trials

DefinitionClinical trials: A rigorously controlled study of a new drug, medical device or other treatment on eligible human subjects subject to oversight

CodesClinical trial-related HCPCS codes referenced (e.g., S9988, S9990, S9991)

AuthorizationPrior authorization is required for clinical trial-related services as indicated

Prior authorization (general)

DefinitionPrior authorization is the approval process providers must use to obtain coverage confirmation from UnitedHealthcare before performing certain elective or scheduled services

SubmissionSubmit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or via 24/7 chat; some services route through separate authorization websites (e.g., Radiation Therapy selection)

ConsequencePayment may be denied if authorization is not obtained prior to service; final coverage decisions depend on plan, eligibility, contract and state law

Prosthetics vs DME

GuidelineProsthetics are distinct from DME; prior authorization rules differ between them

Prosthetics PA thresholdPrior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000

DME PA notesCertain DME require prior authorization (including power mobility and listed A/E codes); some home health services may not be subject to the cost threshold

ESRD dialysis prior authorization

RequirementAdvance notification/prior authorization required for ESRD dialysis services

How to contactFor notification/prior authorization, connect via 24/7 chat on the Contact us page

ScopeApplies to services for treating end-stage renal disease, including outpatient dialysis

Non-routine dialysis

DefinitionNon-routine dialysis — dialysis services identified as requiring prior authorization in multiple entries (policy notes)

ExamplesPolicy references 'Non-routine dialysis' and 'Renal dialysis' across dialysis-related code sections

ActionObtain prior authorization/advance notification for non-routine or renal dialysis services as indicated

Renal dialysis

DefinitionRenal dialysis — services for treating renal failure which may require prior authorization

Codes referencedHemodialysis CPTs (e.g., 90935, 90937) and other dialysis-related HCPCS/CPT codes are listed in the policy

NotificationAdvance notification/prior authorization required for ESRD dialysis services; contact via chat for assistance

Functional endoscopic sinus surgery (FESS)

ProcedureFunctional endoscopic sinus surgery (FESS) procedures

CodesMultiple CPT codes listed (e.g., 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31298)

AuthorizationPrior authorization is required for listed FESS CPT/HCPCS codes

Prior authorization (injectables and process)

DefinitionPrior authorization is the approval process providers must use to obtain coverage confirmation before performing certain procedures or administering specified outpatient injectable chemotherapy/supportive care drugs

Submission methodsSubmit via Prior Authorization and Notification tool on Provider Portal or use Specialty Pharmacy/Transactions tile for injectable drugs; contact Optum 888-397-8129 for online authorization questions

NotificationIf drug prior authorization requirements aren't met, UnitedHealthcare will call the provider's office within 3 days and specialty pharmacy sends authorization letter with number and coverage dates

Prior authorization (procedures)

RequirementPrior authorization is required for listed CPT/HCPCS procedure codes where indicated in the policy

SubmissionUse the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal to submit requests online

Site-of-service reviewSite of service will be reviewed as part of prior authorization for many codes; some office-based exceptions apply (see policy)

Provider submission methods

Submission optionsPredetermination requests can be submitted via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or via Specialty Pharmacy transactions tile for certain drugs

Help/contactFor online authorization questions contact Optum at 888-397-8129

Portal stepsSign in at UHCprovider.com, select the Prior Authorization and Notification tab; for Radiation/Oncology select Radiology/Cardiology/Oncology/Radiation Therapy box which may route to another site

MRgFUS

DefinitionMRgFUS: MR-guided focused ultrasound to treat uterine fibroid

Coverage conditionsCovered for certain benefit plans but requires confirmation of member coverage, contracted facility, written member consent acknowledging limited published evidence, and demonstrated physician/facility experience

DocumentationMember must consent in writing and agree not to hold UnitedHealthcare responsible for dissatisfaction; facility must be contracted with UnitedHealthcare

Unclassified/temporary codes

DefinitionUnclassified/temporary codes (e.g., C9399, J3490, J3590) — prior authorization required only for specific products listed (e.g., Nulibry, Rivfloza, Revcovi)

NoteCheck policy for product-specific authorization requirements when using unclassified or temporary codes

ReferencePolicy indicates limited list of unclassified/temporary codes that require PA for specific drugs

Initial referral for therapy visits

Initial referral validityInitial referral for physical or occupational therapy is valid for up to 8 visits per condition within 6 months from the referral date

If unspecifiedIf number of visits is not indicated on referral, referral valid for one visit only

Additional visitsAdditional visits after the first 8 require preauthorization

Orthotics/prosthetics PA cost threshold

ThresholdPrior authorization is required when orthotics or prosthetics codes are listed with a retail purchase or cumulative rental cost greater than $1,000

Applies toSpecific orthotics L-codes and prosthetics L-codes enumerated in policy (examples shown)

ExceptionsSome home health care services may qualify but are not subject to the cost threshold—see Home health care services section

Standard Radiation Therapy (2D/3D)

DefinitionStandard Radiation Therapy (2D/3D) refers to conventional 2D/3D radiation technique listed in the policy

PA conditionPrior authorization required only when Standard Radiation Therapy (2D/3D) is obtained with specified cancer diagnosis code ranges (see diagnosis list)

Diagnosis ranges exampleC34.00–C34.92; C50.011–C50.929; C61; C79.51–C79.52; C84.7A; D05.00–D05.92

Prior Authorization and Notification tool

Tool namePrior Authorization and Notification tool (UnitedHealthcare Provider Portal)

How to accessSign in at UHCprovider.com using One Healthcare ID, select Prior Authorization and Notification tab; select Radiology/Cardiology/Oncology/Radiation Therapy where applicable

Other methods24/7 chat via Contact us page; phone numbers (e.g., Optum 888-397-8129) available in specific sections

Laboratory-assisted sleep studies / polysomnography

DefinitionLaboratory-assisted sleep studies / polysomnography: facility-based diagnostic sleep studies to diagnose sleep apnea and other sleep disorders

Prior authorization statusPrior authorization is required for facility-based polysomnography; home sleep studies are excluded

Related proceduresSleep apnea surgical procedures and related surgeries also require prior authorization (inpatient and outpatient)

Office-based program exception

ExceptionOffice-based program exception: certain procedures performed in an office setting do not require prior authorization in specified jurisdictions (AK, MA, PR, RI, TX, UT, VI, WI)

ImplicationServices performed in an outpatient hospital setting may require prior authorization even if same service in office does not

Reference codesPolicy lists example CPTs for office-based exceptions in the applicable sections

Site-of-service review

DefinitionSite-of-service review: the site of service will be reviewed as part of the prior authorization process for listed codes

ExceptionsSite-of-service review does not apply in AK, MA, PR, RI, TX, UT, VI and WI for certain codes per policy

ActionVerify site-of-service during authorization to determine if PA required or if office-based exception applies

Transplant prior authorization

RequirementTransplant prior authorization: care providers must request prior authorization for transplant or transplant-related services before pre-treatment or evaluation

ExamplesOrgan or tissue transplant services, bone marrow harvest, and related pre-treatment/evaluation services (e.g., codes like 38240) require PA

Administrative notePredetermination/authorization should be obtained prior to scheduling pre-treatment or evaluation visits; 99205 referenced in evaluation context

Prior authorization for transplant services

RequirementPrior authorization must be requested by care providers for transplant or transplant-related services prior to pre-treatment or evaluation

ScopeApplies to organ or tissue transplant services and related procedures referenced in the policy

Provider actionSubmit predetermination/authorization before pre-treatment or evaluation; verify authorization is on file