CurrentUnitedHealthcarePolicy N/A

Prior authorization requirements for Mississippi Children's Health Insurance Program

Lists services and CPT/HCPCS codes that require prior authorization for UnitedHealthcare Community Plan network providers serving Mississippi Children's Health Insurance Program (CHIP) members, and explains how to submit requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Mississippi Children's Health Insurance Program

Policy CodePolicy N/A

Change TypeNo material changes — informational update

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online, phone, faxways to submit prior authorization requests

877-842-3210prior authorization phone number

888-310-6858prior authorization fax number

Optumbehavioral health network

$500DME auth threshold

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.

4distinct repeated CPT codes

Services Requiring Prior Authorization

Prior authorization-required services (partial list)

The following services and codes require prior authorization for Mississippi CHIP members when provided by network or out‑of‑network providers (out‑of‑network must request authorization for all procedures):

ALL of the following

CPT codes: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846

Behavioral health services must be referred and authorized through the designated behavioral health network (Optum Behavioral Health).

For specific codes call 877-743-8734 or the number on the member's ID card. ABA therapy submissions via fax or Provider Express.

ALL of the following

CPT codes: 20975, 20979

ALL of the following

CPT/HCPCS codes: 11971, 19316, 19318, 19328, 19330, 19350, 19357, 19364, 19367, 19368, 19369, 19370, 19371, 19380, L8600

Prior authorization code list (partial)

This fragment identifies CPT codes that are subjects of prior authorization requirements; no explicit clinical coverage criteria are present in these chunks.

CPT codes: 19367, 19368, 19369, 19370

Prior authorization criteria (selected)

Prior authorization stance and code‑specific notes for outpatient services

ALL of the following

Example HCPCS/J codes: J1449, J1442, Q5110, Q5125, J2506, Q5122, Q5111, Q5108, J1447

ALL of the following

Example ranges/codes: J9000-J9999, J0640, J0641, J0642, J1950, J1952

Bone‑modifying agent denosumab (J0897) requires prior authorization per outpatient cancer supportive care notes.

EXCEPTION: Certain eyelid/skin procedure CPTs (e.g., 67917–67924 and related codes) are noted as not requiring prior authorization when billed with specified diagnosis codes (examples: C43.x, C44.x series).

Prior authorization criteria

Prior authorization rules and exceptions for listed codes

Some CPT/HCPCS codes listed require prior authorization except when billed with specified ICD‑10 diagnosis codes (numerous C43/C44 series exceptions are cited).

Durable medical equipment (DME) requires prior authorization only for the listed codes when retail purchase or cumulative rental cost is more than $500.

Prosthetics are not considered DME under this guidance; orthotics/prosthetics handled separately.

Prior authorization required code groups

Services and codes in these chunks require prior authorization before provision or billing.

ALL of the following

Example B‑codes: B4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4153, B4155, B4158, B4159

ALL of the following

Example codes: A6000, A9274, E0231, E1831, S0810, S1030, S1031, S2102, S9988, S9990, S9991

ALL of the following

Example CPT/HCPCS: 81162, 81163, 81164, 81228, 81229, 81277, 81400-81408, 81410-81417, 81420, 81431-81437, 81439-81445, 81465

Prior authorization coverage criteria

Services and drugs listed below require prior authorization as specified.

Genetic and molecular testing CPT/HCPCS codes listed require prior authorization; the program may require additional registration or outpatient‑setting notes.

ALL of the following

Example codes: 92590‑92595, S0618, V5010, V5011

Home health care prior authorization is required only in outpatient settings, including the member's home (example codes: G0299, G0300, S9474).

A long list of injectable medications (J/Q codes) require prior authorization; providers should submit authorization requests per instructions and note that unclassified/temporary codes may have drug‑specific notes.

Prior authorization criteria (section excerpt)

Prior authorization stance for listed services and codes in this section.

ALL of the following

Example CPTs: 23470, 23472, 23473, 23474, 24360-24363, 24370-24371, 27120-27138, 27412, 27446-27447

ALL of the following

Example CPTs: see listed orthognathic surgery codes (e.g., 21121, 21123, 21125, 21127, 21141-21147, 21150-21155, 21188, 21193-21199, 21206, 21208-21210, 21215, 21240-21249, 21255, 21296, 21299)

Orthotics and prosthetics require prior authorization only when retail purchase or cumulative rental cost is more than $500.

See L‑code lists for specific items.

RECOMMENDATION: For New‑to‑Market medications, providers are advised to check the Review at Launch list and predetermination is highly recommended.

Prior authorization requirements by service

Services and codes that require prior authorization or are subject to specific prior authorization rules:

Advanced outpatient imaging (certain CT, MRI, MRA and PET scans) require prior authorization; ordering providers are responsible for notifying prior to scheduling.

Radiation therapy requires prior authorization for the listed codes; some standard radiation therapy codes require prior authorization only when obtained with specified cancer diagnosis ranges.

Orthotics and prosthetics L‑codes: multiple L‑codes listed require prior authorization.

Private duty nursing requires prior authorization (example codes: S9122, S9123, S9124, T1000‑T1003).

Speech therapy and pain injection procedures may require prior authorization (examples: CPT 92507; pain injection CPTs 64490, 64493).

Prior authorization requirement for listed procedures

Certain CPT/HCPCS codes and categories require prior authorization; detailed code lists and how to obtain prior authorization are available via Radiology Prior Authorization resources referenced throughout.

Septoplasty, rhinoplasty and sinuplasty CPTs are subject to prior authorization; providers should consult Radiology Prior Authorization resources for the specific CPT lists and submission instructions.

Coverage criteria — selected services requiring prior authorization

Coverage stance and requirements for selected procedure categories in this section:

Sleep apnea procedures and oral‑pharyngeal tissue reduction procedures for obstructive sleep apnea require prior authorization (example CPTs referenced).

Spinal surgery listed CPTs require prior authorization (examples include 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, and related spinal surgery series).

Stimulator device implantation (devices that send electrical impulses) requires prior authorization; example device HCPCS include E0747–E0760 and related neurostimulator CPTs.

Transplants and CAR T‑cell therapy require prior authorization; providers must contact UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card.

Transplant and CAR T-cell therapy

Prior authorization required for transplant and CAR T‑cell therapy services.

Prior authorization is required for transplant and CAR T‑cell therapy services (including Abecma, Breyanzi, Kymriah, Tecartus, Yescarta).

Providers must call UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card.

Vein procedures, VAD, Wound VAC

Prior authorization required for vein procedures and ventricular assist devices.

ALL of the following

Example CPTs: 36473, 36475, 36478, 37700

ALL of the following

Example CPT/HCPCS: 33927, 33928, 33929, 33975, 33976, 33979, Q0507

Wound VAC devices require prior authorization (example HCPCS: E2402).

CPT / HCPCS / J / Q Code Lists and Notes

Bariatric surgery codesCPTCovered

43644	Bariatric surgery code listed as requiring prior authorization
43645	Bariatric surgery code listed as requiring prior authorization
43659	Bariatric surgery code listed as requiring prior authorization
43770	Bariatric surgery code listed as requiring prior authorization
43775	Bariatric surgery code listed as requiring prior authorization
43842	Bariatric surgery code listed as requiring prior authorization
43845	Bariatric surgery code listed as requiring prior authorization
43846	Bariatric surgery code listed as requiring prior authorization

Bone growth stimulator codesCPTCovered

20975	Bone growth stimulator (electronic stimulation) code listed
20979	Bone growth stimulator code listed

Breast reconstruction / mastectomy codesmixedCovered

11971	Breast reconstruction related code listed
19316	Breast reconstruction related code listed
19318	Breast reconstruction related code listed
19328	Breast reconstruction related code listed
19330	Breast reconstruction related code listed
19350	Breast reconstruction related code listed
19357	Breast reconstruction related code listed
19364	Breast reconstruction related code listed
19367	Mastectomy/reconstruction related code listed
19368	Mastectomy/reconstruction related code listed

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Repeatedly listed CPT codesCPT

19367	CPT code referenced in document
19368	CPT code referenced in document
19369	CPT code referenced in document
19370	CPT code referenced in document

Cancer supportive care and related injectablesHCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)
J1447	Tbo-filgrastim (Granix)
J1454	Akynzeo (palonosetron/fosnetupitant)

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Chemotherapy injectablesHCPCSCovered

J9000-J9999	Chemotherapy injectable drugs range
J0640	Leucovorin
J0641	Levoleucovorin
J0642	Levoleucovorin variant
J1950	Lupron Depot
J1952	Leuprolide

Cochlear and implantable hearing device codesmixedCovered

69710	Cochlear procedure
69714	Cochlear procedure
69930	Cochlear device procedure
L8614	Implantable inner ear device HCPCS
L8619	Implantable inner ear device HCPCS
L8690	Implantable inner ear device HCPCS
L8691	Implantable inner ear device HCPCS
L8692	Implantable inner ear device HCPCS

Eyelid/skin lesion CPT codes with PA notesCPTCovered

67917	Eyelid/lesion related CPT code
67921	Eyelid/lesion related CPT code
67922	Eyelid/lesion related CPT code
67923	Eyelid/lesion related CPT code
67924	Eyelid/lesion related CPT code
67950	Related eyelid procedure CPT
67961	Related eyelid procedure CPT
67966	Related eyelid procedure CPT

DME HCPCS codes with prior authorization notesHCPCS

A6549	DME HCPCS code listed
B4152	DME HCPCS code listed
E0266	DME HCPCS code listed
E0328	DME HCPCS code listed
A9279	DME HCPCS code listed
B4161	DME HCPCS code listed
E0270	DME HCPCS code listed
E0329	DME HCPCS code listed
E0465	DME HCPCS code listed
E0483	DME HCPCS code listed

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Sample DME HCPCS codesHCPCSCovered

E0745	Durable medical equipment HCPCS code listed
E0762	Durable medical equipment HCPCS code listed
E0764	Durable medical equipment HCPCS code listed
E0766	Durable medical equipment HCPCS code listed
E0784	Durable medical equipment HCPCS code listed

Additional DME codesHCPCSCovered

T1999	DME miscellaneous HCPCS code
T5999	DME miscellaneous HCPCS code
V2786	DME HCPCS code
V5269	DME HCPCS code

Genetic/molecular CPT/HCPCSCPTCovered

81162	Genetic/molecular testing
81163	Genetic/molecular testing
81164	Genetic/molecular testing
81228	Genetic testing
81229	Genetic testing
81277	Genetic testing
81400	Molecular testing series (multiple)
81401	Molecular testing
81402	Molecular testing
81403	Molecular testing

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Hearing aid CPT/HCPCSCPTCovered

92590	Hearing aid services
92591	Hearing aid services
92592	Hearing aid services
92593	Hearing aid services
92594	Hearing aid services
92595	Hearing aid services
S0618	Hearing-related code
V5010	Hearing aid related

Selected injectable J-codes (sample)HCPCSCovered

J3262	Actemra
J0801	Acthar
J0791	Adakveo
J0172	Aduhelm

Injectable medications examplesHCPCSCovered

J9226	Syfovre™
J2781	Synagis®
90378	Tepezza®
J3358	Stelara

Orthotics/Prosthetics example codesHCPCSCovered

L0112

Orthotic/prosthetic code (example)

L-codes (orthotics/prosthetics)HCPCSCovered

L5560	Listed L-code requiring prior authorization (orthotics/prosthetics) as shown in list
L5595	Listed L-code requiring prior authorization (orthotics/prosthetics) as shown in list
L5580	Listed L-code requiring prior authorization (orthotics/prosthetics) as shown in list

Radiation therapy codesCPT | HCPCSCovered

77014	Radiation therapy imaging/procedure code listed
77387	Radiation therapy code listed
G6001	Radiation therapy-related HCPCS listed
77385	Intensity-Modulated Radiation Therapy (listed)

Private duty nursingHCPCSCovered

S9122	Private duty nursing code listed
S9123	Private duty nursing code listed
S9124	Private duty nursing code listed
T1000	Private duty nursing/home health code listed

Therapies and pain injectionsCPTCovered

92507	Speech therapy CPT code; prior authorization required
64490	Pain injection code listed
64493	Pain injection code listed

ENT procedures (examples)CPT

30400-30435	Septoplasty and rhinoplasty CPT range referenced
31295-31298	Sinuplasty CPT codes referenced

Digestive system procedures (examples)CPT

43200-43259	Digestive system / upper GI procedure CPT range referenced
44360	Additional digestive system code referenced

Integumentary and other proceduresCPT

10121, 11440-11624, 13121, 15100-15120	Integumentary / skin procedure codes referenced
47000	Liver biopsy CPT code referenced

Example CPT codes mentionedCPT

29806	Arthroscopy code listed under outpatient hospital
43235	Upper gastrointestinal endoscopy code
22100	Spinal surgery code (listed among spinal surgery CPTs)

Device/HCPCSHCPCS

E0747	Electrical stimulator device
E0748	Electrical stimulator device
E0749	Electrical stimulator device
E0760	Electrical stimulator device

Surgical/transplant-related CPT codesCPT

38232	Bone marrow harvest or related procedure (listed with asterisk in source)
44132	Enterectomy / related GI procedures
44715	Resection procedures

HCPCS Q-codesHCPCS

Q2041	HCPCS - specific device/procedure code
Q2042	HCPCS - specific device/procedure code
Q2053	HCPCS - specific device/procedure code
Q2055	HCPCS - specific device/procedure code
Q2056	HCPCS - specific device/procedure code

inv-40: PA not required when billed with specific diagnosis codes

Exception summaryPrior authorization is NOT required for listed eyelid/skin lesion CPT codes (examples: 67917–67924 and related codes) when billed with specified ICD-10 diagnosis codes in the C43.x and C44.x series.

How to Obtain Prior Authorization and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

This list contains prior authorization requirements for UnitedHealthcare Community Plan network health care professionals who provide inpatient and outpatient services to Mississippi Health Insurance Program (CHIP) members. Please submit your prior authorization 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 your One Healthcare ID and password and select the Prior Authorization and Notification tab. Phone: 877-842-3210. Fax: 888-310-6858. 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.

Online: Prior Authorization and Notification tool on UHCprovider.com (One Healthcare ID required)
Phone: 877-842-3210
Fax: 888-310-6858
Prior authorization not required for emergency or urgent care
Out-of-network providers must request prior authorization for all procedures/services

Prior Authorization

Cancer supportive care drugs requiring prior authorization

Key Terms and Notes

inv-82: Prior authorization is approval from the health plan required before certain services are performed; not required for emergency or urgent care.

DefinitionPrior authorization is approval from the health plan required before certain services are performed; not required for emergency or urgent care.

Who must requestOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Submission methods (summary)Online, phone, fax (details provided elsewhere in the policy).

inv-83: Optum Behavioral Health network used for behavioral health service referrals and prior authorization

Behavioral health networkOptum Behavioral Health is the designated network for behavioral health service referrals and prior authorization.

Contact for specific codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization requirements for Mississippi Children's Health Insurance Program

Policy CodePolicy N/A

Change TypeNo material changes — informational update

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal, by phone at 877-842-3210, or by fax at 888-310-6858.

SourceLink

On This Page

Certain ENT and digestive procedures (e.g., septoplasty, rhinoplasty, sinuplasty, selected upper GI procedures) are included; radiology/site‑of‑service rules may apply for nuclear medicine and nuclear cardiology procedures.

Affected CPT codes (examples)

67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966

Triggering diagnosis codesICD-10 codes in the C43.x and C44.x ranges (multiple specific subcodes cited in the source).

Reference noteThis is a billing-time exception: when the procedure is billed with the listed malignant skin neoplasm diagnosis codes, PA is not required.

inv-41: DME prior authorization cost threshold

ThresholdPrior authorization required only for DME items with a retail purchase or cumulative rental cost of more than $500.

ScopeApplies to durable medical equipment (DME) codes listed in the policy; prosthetics are not considered DME for this threshold.

Example codes referencedMultiple E- and A- HCPCS codes listed in the DME sections (see source list).

inv-42: Orthotics/prosthetics PA cost threshold

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

ScopeApplies to the listed L‑codes for orthotics and prosthetics in the policy; many specific L‑codes are enumerated (see code list).

Example L-codeL0112 cited as an example in the orthotics/prosthetics list.

Prior authorization is required for colony-stimulating factor drugs, certain anti-emetic agents and bone-modifying agents administered in an outpatient setting for a cancer diagnosis. Submit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) or call the number on the member's ID card.

Colony-stimulating factors requiring prior authorization: Filgrastim products (Neupogen® and biosimilars Q5110/Q5125/Q5101/Q5111 etc.; J1449, J1442), Pegfilgrastim products (Neulasta® J2506 and biosimilars Q5122/Q5111/Q5108 etc.), Sargramostim (Leukine®), Tbo-filgrastim (Granix® J1447).
Anti-emetic drugs requiring prior authorization: Akynzeo® (palonosetron/fosnetupitant) J1454, J1456; Emend® (fosaprepitant) J0185, J1627.
Bone-modifying agent requiring prior authorization: Denosumab (Xgeva®) J0897.
Erythropoiesis-stimulating agents and other supportive agents may also require authorization per clinical indication—refer to portal guidance.

Prior Authorization

Cochlear devices prior authorization

Prior authorization is required for cochlear implants and related procedures/devices. Providers should submit requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call the number on the member's ID card for assistance.

Relevant CPT/HCPCS codes: 69710, 69714, 69930 and device codes L8614, L8619, L8690, L8691, L8692.
Prior authorization required for implantation and associated device billing.

Prior Authorization

PA exceptions for specific diagnosis codes

Some CPT codes listed for procedures have exceptions where prior authorization is not required when billed with specified diagnosis codes (ICD-10). Check the charted code exceptions and verify billing diagnosis to determine if a prior authorization is required.

Examples: Prior authorization not required for certain eyelid/excision codes when billed with melanoma/C43 or skin cancer/C44 diagnosis codes listed in the source (see specific code/diagnosis pairings in portal/reference).
Always confirm exception pairs on the provider portal or contact provider services if unsure.

Prior Authorization

Injectable medications requiring prior authorization

Many injectable medications require prior authorization. Submit requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 888-397-8129 for assistance. Predetermination is recommended for new-to-market medications.

Representative injectable drugs that require prior authorization include (not exhaustive): Actemra® J3262; Acthar® J0801; Adakveo® J0791; Aldurazyme® J1931; Amvuttra™ J0225; Benlysta J0490; Beqvez J1414; Berinert® J0597; Botulinum toxins J0585/J0587/J0588; Brineura™ J0567; Briumvi® J2329; Cerezyme® J1786; Cimzia® J0717; Cinqair® J2786; Cortrophin® Gel J0802; Eylea HD J0177; Fabrazyme® J0180; Feraheme® Q0138; Gamifant® J9210; Givlaari® J0223; Hemgenix® J1411; Ilaris® J0638; Inflectra® Q5103; Injectafer® J1439; Izervay J2782; Kanuma® J2840; Krystexxa® J2507; Lupron Depot® J1950; Luxturna™ J3398; Naglazyme® J1458; Nplate®; Ocrevus™ J2350; Onpattro™ J0222; Orencia® J0129; Panzyga® J1576; Prolia® J0897 (note: for J0897 prior authorization required for non-oncology diagnosis); Vyepti™ J3032; and many others listed in the portal.
Unclassified/temporary codes (C9159, C9172, C9399, J3490, J3590): prior authorization applies only for specified products (e.g., Nulibry™, Rivfloza).
For drugs newly approved by FDA, check the 'Review at Launch for New to Market Medications' guidance and consider predetermination.

Prior Authorization

Orthognathic surgery prior authorization

Orthognathic surgery for treatment of maxillofacial/jaw functional impairment requires prior authorization. Submit requests through the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Relevant CPT codes include 21121, 21123, 21125, 21127, 21141–21151, 21154–21160, 21188, 21193–21199, 21206, 21208–21210, 21215, 21240–21249, 21255, 21296, 21299 and others listed in the orthognathic section.
Prior authorization required to confirm functional impairment criteria and medical necessity before scheduling.

Prior Authorization

Vein procedures and VAD prior authorization

Vein procedures (removal/ablation of saphenous trunks and named branches) and ventricular assist device (VAD) services require prior authorization. Follow the portal submission process or contact the numbers below as specified for VAD coordination.

Vein procedure CPT codes requiring prior authorization include 36473, 36475, 36478, 37700.
Ventricular assist devices (VADs) require prior authorization. For VAD services, 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. Relevant CPT/HCPCS codes include 33927, 33928, 33929, 33975, 33976, 33979, 33981, 33982 and Q0507.
Ensure authorization before scheduling; clinical case management coordination is required for VAD placement and ongoing management.

Note

How to Obtain Prior Authorization

For all prior authorization submissions: use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) whenever possible. If the portal is not available, use the phone numbers listed in this section or the fax numbers provided by clinical teams (for example Optum VAD Case Management fax 855-282-8929). Always verify the member's plan-specific contact number on the back of the member's ID card for specialty programs (transplant, VAD, etc.).

Primary portal: UHCprovider.com -> Prior Authorization and Notification tile
General phone: 877-842-3210; drug prior auth line: 888-397-8129; transplant case management: 888-936-7246; VAD fax: 855-282-8929
Use member ID card contact numbers for program-specific notifications

Call 877-743-8734 or the number on the member's ID card for codes requiring authorization or referrals.

ABA submissionsApplied behavior analysis (ABA) therapy submissions are via fax or Provider Express.

inv-84: how to obtain prior authorization

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

Phone alternativesPhone numbers provided in the document include 877-842-3210 and 888-397-8129 (used for certain drug prior authorizations); other sections list additional phone contacts for specific services.

Portal navigationSign in with One Healthcare ID, select the Prior Authorization and Notification tile on the dashboard to start a request.

inv-85: Prior authorization requirement (oncology outpatient)

RequirementPrior authorization is required for colony-stimulating factor drugs, bone‑modifying agents and injectable chemotherapy drugs administered in an outpatient setting for a cancer diagnosis.

Example HCPCS/J-codesExamples include J1449, J1442, Q5110, J2506 and broad ranges J9000-J9999 for chemotherapy injectables.

How to submitRequests should be submitted online via the Provider Portal; alternative phone contact (866-889-8054) is noted in oncology/cardiology sections.

inv-86: How to obtain prior authorization

Primary instructionSubmit prior authorization requests online via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal.

Drug-specific phoneFor some injectable medications the document provides phone alternative 888-397-8129; oncology/cardiology sections reference 866-889-8054 for specific workflows.

Unclassified/temporary codes noteFor unclassified/temporary codes and certain products, special prior authorization rules and product-specific notes apply (see policy).

inv-87: Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME) — prior authorization is required only for listed DME codes when the retail purchase or cumulative rental cost exceeds $500.

ExclusionsProsthetics are not treated as DME under this threshold and are handled under orthotics/prosthetics guidance.

ExamplesMultiple HCPCS E- and A- codes are enumerated in the DME sections of the policy; enteral/parenteral B‑codes also require authorization (see B4034, B4035, B4036, etc.).

inv-88: Prior authorization

Primary definitionPrior authorization — the health plan's approval required before certain services are performed; submit requests via the Provider Portal, by phone, or by fax.

Submission channelsOnline via Prior Authorization and Notification tool (UHCprovider.com), phone (noted numbers include 877-842-3210 and 888-397-8129), or fax (888-310-6858).

Emergency carePrior authorization is not required for emergency or urgent care.

inv-89: Experimental/investigational

DefinitionExperimental/investigational services — treatments or linked services identified by listed CPT/HCPCS codes that require prior authorization.

ExamplesThe policy lists numerous codes marked as experimental/investigational (e.g., 36514, 64722, A6000, E0231 and others in the experimental list).

RequirementPrior authorization is required for these services before provision or billing.

inv-90: Home health prior authorization

RequirementHome health care prior authorization is required only in outpatient settings, including the member's home.

Example codesG0299, G0300, S9474 are cited as home health care codes in the policy.

ScopeApplies to services provided in outpatient settings; inpatient home health contexts differ and are not included here.

inv-91: Prior authorization

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

Portal stepsSign in with One Healthcare ID, select the Prior Authorization and Notification tile on your dashboard to create and submit requests.

Phone alternativePhone numbers listed in the policy (e.g., 877-842-3210, 888-397-8129 or other service-specific lines) may be used where indicated.

inv-92: Unclassified/temporary code note

NoteUnclassified and temporary codes C9159, C9172, C9399, J3490 and J3590 require prior authorization only for specific products (Nulibry™ and Rivfloza as noted).

ActionCheck product-specific notes in the policy when billing under unclassified/temporary HCPCS codes before submitting authorization requests.

ReferenceSee injectable medications / unclassified code section for details and exceptions.

inv-93: J0897 requirement

RequirementJ0897 (denosumab) requires prior authorization for non‑oncology diagnoses.

ContextJ0897 is listed among bone‑modifying agents and has a specific authorization requirement when used outside oncology supportive care.

ActionSubmit authorization via the Provider Portal using the standard prior authorization workflow; review code-specific notes in the policy.

inv-94: Focused radiation therapy that uses beams of protons

DefinitionProton Beam — focused radiation therapy that uses beams of protons.

Related codesProton beam therapy CPT/HCPCS examples cited include 77520–77525 and associated radiation therapy codes (see radiation therapy section).

Authorization stanceRadiation therapy procedures (including proton beam) require prior authorization as described in the radiation therapy section.

inv-95: Prior Authorization and Notification (Provider Portal)

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

How to accessSign in with One Healthcare ID, select the Prior Authorization and Notification tile on the dashboard to begin submissions.

Use casesUsed for prior authorization submissions for radiology, cardiology, oncology, radiation therapy and many other services listed in the policy.

inv-96: Site of service (SOS)

DefinitionSite of service (SOS) — outpatient hospital setting where certain procedures may require prior authorization (site‑of‑service rule applies).

ImplicationPrior authorization may be required when requesting nuclear medicine and nuclear cardiology procedures in an outpatient hospital setting.

Reference actionConsult the Radiology Prior Authorization resources referenced in the policy for service‑specific code lists and submission rules.

inv-97: Site of service (SOS)

SOS detailSite of service (SOS) — outpatient hospital (continued); multiple ophthalmology and other outpatient hospital CPTs are listed as examples where SOS considerations apply.

ExamplesCPTs cited in the site‑of‑service sections include 66761, 67028, 67036, 67040 and others across outpatient hospital listings.

ActionOrdering providers are responsible for notifying and obtaining authorization prior to scheduling advanced outpatient imaging or procedures at the outpatient hospital site.

inv-98: Transplant Case Management contact

ContactCall UnitedHealthcare Community and State Transplant Case Management at 888-936-7246 or use the notification number on the member's ID card for transplant and CAR T-cell therapy prior authorization.

Services coveredPrior authorization required for transplant and CAR T‑cell therapy services (examples: Abecma, Breyanzi, Kymriah, Tecartus, Yescarta).

Process noteProviders must contact Transplant Case Management as specified rather than using the standard portal workflow for these services.

inv-99: Ventricular assist device (VAD)

RequirementVentricular assist devices (VAD) require prior authorization.

DefinitionVAD — a mechanical pump that takes over function of a damaged ventricle and restores blood flow.

Authorization processCall the notification number on the member's ID card and fax the Optum VAD Case Management team at 855-282-8929 with the provided form; codes cited include 33927, 33928, 33929, 33975, 33976, 33979.

inv-100: Vein procedures (saphenous)

RequirementVein procedures involving removal/ablation of saphenous trunks require prior authorization.

Example CPT codes36473, 36475, 36478, 37700 are cited for saphenous vein procedures.

Related devicesVAD and other related device codes (e.g., 33927–33979) are addressed in adjacent sections with specific submission instructions.