Coverage criteria and rules (partial — document continues)
Advance prior authorization is required for the listed procedure and service categories for all Neighborhood Health Partnership (NHP) plan members in both outpatient and inpatient settings, unless otherwise noted. Emergency or urgent care does not require advance prior authorization. Out-of-network providers must request prior authorization for procedures/services (excluding emergent or urgent care). Submit requests via the UnitedHealthcare Provider Portal Prior Authorization and Notification tool, by phone, or chat as noted per service.
General rules: Prior authorization is required for participating providers for many outpatient and inpatient procedures and services. Advance prior authorization is not required for emergency or urgent in- and out-of-area care. Site-of-service (SOS) review may apply — some codes require review of appropriate setting (office vs ASC vs outpatient hospital) as part of prior authorization.
How to obtain authorization: Use the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com) — sign in with One Healthcare ID. If no One Healthcare ID, visit UHCprovider.com/access. Phone and portal numbers referenced in the policy (e.g., 866-889-8054, 888-397-8129) are available for certain service lines; specialty contact details appear with specific service entries. Chat is available 24/7 via the Contact us page for notifications, case management starts, and some prior authorization requests.
Documentation and review: Prior authorization reviews include clinical indication, diagnosis codes, and may include site-of-service appropriateness. For some services (e.g., bariatric surgery, MRgFUS, cochlear implants), plan-specific coverage limits (Centers of Excellence requirements, plan exclusions) apply. Predetermination is recommended for new-to-market medications listed on the Review at Launch Medication List.
Codes and exceptions: Specific CPT/HCPCS/ICD-10 codes are listed with each service category below. Some codes are conditioned by diagnosis (for example, certain cosmetic/procedural codes do not require authorization when billed with specified malignancy diagnosis codes). For drugs and miscellaneous HCPCS (e.g., unclassified codes C9172, C9399, J3490, J3590), prior authorization applies only for named products per the policy notes.
Provider responsibilities: Ensure prior authorization is obtained before planned services subject to authorization. For inpatient post-acute facility admissions, prior authorization and notification of admission date are required for listed facility types (acute care hospitals, acute inpatient rehab, critical access, LTAC, skilled nursing). Advance notification is required for ESRD out-of-network referrals and for some implantable device case management starts.
Appeals and medical necessity: Requests are reviewed against UnitedHealthcare medical policies and benefit plan terms. Some services may be denied as not medically necessary (e.g., Aduhelm for Alzheimer's per current medical drug policy). For drugs on Review at Launch, predetermination is highly recommended.
Operational notes: Prior authorization may be required only for outpatient settings (e.g., cerebral seizure monitoring inpatient services may require authorization whereas outpatient EEG may not). Some DME/orthotics/prosthetics require authorization only when retail purchase or cumulative rental exceeds $1,000. Site-of-service exemptions apply in certain states (Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, Virgin Islands and Wisconsin) as noted per code lists.
Cancer supportive care prior authorization
Cancer supportive care injectable drugs administered in outpatient settings require prior authorization. Certain colony-stimulating factors, anti-emetics, bone-modifying agents, erythropoiesis-stimulating agents, and chemotherapy injectables are subject to authorization. Some biosimilars and HCPCS Q-codes are included; select codes may also require authorization for non-oncology diagnoses. See provider portal or pharmacy specialty pages for details.
Prior authorization required for outpatient-administered colony-stimulating factor drugs for a cancer diagnosis (examples include J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5126; note: these codes also require prior authorization for non-oncology DX as specified in the Injectable medications section).
Anti-emetics requiring prior authorization: Akynzeo (palonosetron/fosnetupitant) J1454/J1456; Cinvanti (aprepitant) J0185; Emend (fosaprepitant) J1453; Sustol (granisetron ER) J1627 — prior authorization required per list.
Bone-modifying agents: Denosumab (Prolia, Xgeva) J0897 requires prior authorization.
Erythropoiesis-stimulating agents: Epoetin alfa J0885 requires prior authorization (note: J0885 requires authorization for both oncology and non-oncology Dx except prior authorization is not required for ESRD diagnosis per policy footnote).
Cardiology and cardiovascular prior authorization
Cardiology and cardiovascular outpatient and office-based diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echoes require prior authorization for participating physicians. Vascular codes (including lower extremity angiogram/angioplasty/stent procedures) and selected device/implant codes require authorization and may have site-of-service review.
Cardiology prior authorization: Participating physicians must obtain prior authorization for outpatient and office-based diagnostic catheterizations, electrophysiology implants, echocardiograms, and stress echocardiograms. Submit requests via the Prior Authorization and Notification tool on the Provider Portal or call 866-889-8054 for details and code lists.
Selected cardiovascular CPT/HCPCS examples requiring authorization: pacemaker/implant-related codes such as 33285; vascular interventional codes including 37220*, 37221*, 37224*, 37229*, 37231* (lower extremity angiogram/angioplasty/stent) require prior authorization — lower extremity angiogram authorization applies per policy notes.
Electrophysiology and device codes: 93580**, 93653, 93656 and associated device supply codes (e.g., E0616) are included where noted and require prior authorization.
Congenital heart disease: Specific procedural requirements and authorization processes for patients under age 18 are referenced in the Congenital Heart Disease section of the document — those cases may have separate prior authorization pathways.
Authorization requirement criteria (partial)
Authorization requirement criteria and site-of-service rules: Several procedures require prior authorization depending on the setting (office vs outpatient hospital vs ambulatory surgery center). Some services are subject to SOS review and may be authorized only in specific settings. Prior authorization requirements may be waived for certain states as noted.
Site-of-service (SOS) program: Prior authorization is required if services are performed in an outpatient hospital setting or ambulatory surgery center (ASC) as specified for particular codes. In many cases prior authorization is not required for services performed in a participating ASC; prior authorization may still be required when performed in an outpatient hospital.
State exceptions: SOS prior authorization is not required for health care professionals in Alaska, Massachusetts, Puerto Rico, Rhode Island, Texas, Utah, the Virgin Islands and Wisconsin for certain services per policy notes.
Examples of SOS-applied services: Arthroscopy codes (e.g., 29826, 29843, 29871) — site-of-service will be reviewed as part of prior authorization in most states (exceptions noted). Foot surgery and multiple ENT/otolaryngology procedures include SOS review. Facial/plastic/cosmetic procedures may have SOS considerations.
Operational note: When SOS review applies, the authorization decision may factor in clinical appropriateness of the ambulatory setting versus outpatient hospital. Providers should confirm the intended setting when submitting prior authorization requests.
Prior authorization and coverage rules (excerpt)
This group summarizes additional prior authorization and coverage rules across multiple service categories (cosmetic/reconstructive, DME, genetic testing, cochlear implants, chemotherapy, radiation therapy, prosthetics/orthotics, pain management, home health, surgical categories). Codes listed are illustrative; full code lists live in the policy details.
Cosmetic and reconstructive procedures: Prior authorization is required for all states for the listed CPT codes (examples include 11960, 11970, 11971, 14020*, 14021*, 14061*, 14302, 15570, 15572). Some cosmetic procedures are not covered unless medical necessity criteria are met.
Durable Medical Equipment (DME), orthotics, prosthetics: Prior authorization required for identified DME/orthotics/prosthetics codes when retail purchase or cumulative rental cost exceeds $1,000 (examples: A7025, A7026, E0194, E0265, E0266, E0277, E0296, E0297, E0300, E0302, E0304). Certain DME items (pneumatic compressors K0854-K0857) require prior authorization.
Genetic and molecular testing including BRCA: Prior authorization required for listed genetic testing CPT codes (examples: 81162-81164, 81228-81229, 81277, 81349, 81400-81407, 0473U-0509U and S-codes listed). Submit genetic testing prior authorization via the Provider Portal.
Cochlear and auditory implants: Prior authorization and/or advance notification required (HCPCS L8614 and S9988/S9990/S9991 mappings). Advance notification may initiate case management and utilization management processes.
Authorization/notification criteria
Authorization/notification criteria and special programs: some services require advance notification rather than full prior authorization; others require both authorization and case management start (e.g., cochlear implants, ESRD out-of-network referrals).
Advance notification: For some services (e.g., cochlear implants, ESRD out-of-network referrals, certain site-of-service programs), providers should initiate advance notification via chat or the contact number on the member ID card to start case management and utilization management.
Notification vs prior authorization: The policy distinguishes advance notification (to start care management) from full prior authorization (which must be obtained before services are performed). Confirm per-service requirement in the full code lists — some entries read 'advance notification encouraged' or 'advance notification required' while others read 'prior authorization required.'
State and setting caveats: For SOS office-based programs, prior authorization may be required if performed in an outpatient hospital setting or ASC; participating providers in certain states have SOS exemptions. When in doubt, submit notification and request guidance via chat or portal.
How to obtain: Use Provider Portal for prior authorization submissions. For advance notification or case management starts, chat 24/7 via Contact us page is available; phone numbers on the member's health plan ID card may route to specialty review teams.
Partial coverage criteria and prior authorization rules
Partial coverage criteria and prior authorization rules: Some items are covered only for specific diagnoses, when clinical criteria are met, or when provided at an approved Center of Excellence. Others are explicitly not covered or considered experimental. Refer to service-level entries for detailed coverage determinations.
Coverage conditioned on diagnosis: Several procedural codes require prior authorization except when billed with specified diagnosis codes (example: certain oncologic CPTs are exempt when billed with listed C43/C44 codes). Check the diagnosis exceptions listed with each code group.
Centers of Excellence: Bariatric surgery and related obesity services require Center of Excellence designation for coverage per policy; some plans may exclude bariatric surgery entirely — verify benefit plan coverage before authorization.
Not medically necessary / experimental exclusions: Per UnitedHealthcare medical drug and device policies, some therapies (e.g., Aduhelm for Alzheimer's disease) are considered unproven and not medically necessary and will not be authorized.
DME/orthotics/prosthetics thresholds: Prior authorization required only when retail purchase or cumulative rental cost exceeds $1,000 for specified codes; otherwise standard coverage rules apply.
Prior authorization and coverage notes
Prior authorization and coverage notes: contact paths, footnotes and policy references. Some services reference external UnitedHealthcare resources (Review at Launch list, specialty pharmacy drug lists, cardiology prior authorization pages) for up-to-date lists and guidance.
Review at Launch and specialty pharmacy: Check the Review at Launch for New to Market Medications policy for up-to-date information and predetermination recommendations. Specialty pharmacy drug lists and prior authorization forms are available on the UnitedHealthcare website.
Provider Portal and phone contacts: Use the Provider Portal Prior Authorization and Notification tool or call the specialty numbers provided in the policy (e.g., 888-397-8129 for certain pharmacy cases; 866-889-8054 for cardiology). For advance notification and case management starts, chat is available 24/7.
Footnotes: Policy contains footnotes clarifying that for some codes prior authorization is required for both oncology and non-oncology diagnoses, and that some codes are exempt for ESRD diagnosis. For unclassified HCPCS and miscellaneous codes, prior authorization applies only to specifically named products.
Where to find code specifics: Full code lists, diagnosis exceptions, and state-specific SOS exception information are maintained within the full prior authorization policy document and the referenced UnitedHealthcare web resource links.
Administrative prior authorization criteria (partial)
Administrative prior authorization criteria (partial): Certain administrative rules apply (predetermination recommended for new-to-market drugs, prior authorization pathways differ by service line) and selected service groups require targeted administrative routing.
Predetermination: Highly recommended for drugs on the Review at Launch Medication List and for new-to-market therapies that may use unclassified or temporary HCPCS codes.
Routing and specialty contacts: Some service lines (e.g., cardiology, radiation oncology, chemotherapy infusions, specialty injectable therapies, cochlear implants) have dedicated prior authorization workflows and contact numbers; follow the service-level instructions in the policy.
Unclassified/temporary codes: For codes such as C9172, C9399, J3490 and J3590, prior authorization is required only for the named therapies called out in the footnotes (e.g., Nulibry, Ocrevus Zunovo, Rivfloza, Revcovi).
Prior authorization requirements
Prior authorization requirements (continues): Many surgical and procedural categories require prior authorization; providers should consult the full policy for the comprehensive code lists and any diagnosis-based exceptions.
Surgical categories that require prior authorization include (but are not limited to): arthroscopy, bariatric surgery, breast reconstruction (non-mastectomy), cartilage implants, cochlear and auditory implants, orthognathic surgery, rhinoplasty, sinus procedures (FESS, sinuplasty), foot surgery, hysterectomy (inpatient), and certain genital organ surgeries.
Interventional procedures and monitoring: Cerebral seizure monitoring (codes 95700-95718, 95720, 95722-95726) may require prior authorization for inpatient services; outpatient EEGs often do not require prior authorization for outpatient hospital or ASC settings per policy notes.
Radiation therapy and complex oncology procedures: Prior authorization required for type and modality (IMRT, IGRT, proton beam) and to ensure appropriate planning and fractionation per clinical guidelines.
Authorization and SOS criteria
Authorization and site-of-service (SOS) criteria: Many musculoskeletal, pain management, ENT, and outpatient surgical procedures include SOS-based authorization rules. When SOS applies, prior authorization focuses on appropriate setting and clinical necessity.
Musculoskeletal and pain procedures: Several musculoskeletal and pain management CPT codes (examples include 64490, 64493, 64633, 64640, 64721, 66984) have prior authorization or SOS review requirements depending on setting. Carpal tunnel surgery (64721) is listed with prior authorization notes in multiple sections.
ENT and auditory system procedures: Auditory system outpatient hospital SOS entries (e.g., 69100, 69205, 69140, 69145) may require authorization when performed in an outpatient hospital; participating ASCs may be exempt.
Operational caveat: Submissions should indicate the intended setting; if requesting a higher-cost outpatient hospital setting, include clinical justification to support SOS choice to reduce denial risk.
SOS-based authorization criteria
SOS-based authorization criteria (partial): When procedures can be performed in office or ASC settings, prior authorization may be required for outpatient hospital settings only. Providers should review code-level guidance for SOS determinations and state-specific exceptions.
Examples: Office-based program procedures performed in an outpatient hospital or ASC may require prior authorization; the policy lists numerous procedural codes where SOS-based prior authorization applies.
State exceptions and participating provider rules: For specified states, prior authorization for SOS may not be required for participating providers. Confirm per-code and per-state guidance within the full policy.
Practical guidance: To minimize denials, indicate actual planned site-of-service on the authorization request and provide rationale if requesting outpatient hospital rather than office/ASC setting.
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(untitled) — additional coverage criteria: Consolidated notes for repeated or miscellaneous entries present throughout the source that must be represented in this section (e.g., repeated per-code authorization statements, reminders to use Provider Portal or phone contact, and recurring site-of-service exceptions).
Repeated provider guidance: The policy frequently repeats the instruction to submit prior authorization requests via the Provider Portal Prior Authorization and Notification tool (UHCprovider.com Sign In) and to use chat for notifications and case management initiation. Phone contacts (e.g., 866-889-8054, 888-397-8129) are provided for certain service lines.
Per-code repetition: Multiple code groups in the source reiterate that 'prior authorization required' applies for the listed CPT/HCPCS codes and that site-of-service review will occur for many codes except in enumerated states. This section consolidates that repeated rule — verify code-specific details in the full policy lists.
Operational reminders: When a code is marked with an asterisk or other footnote in the policy, consult the footnotes for diagnosis or setting exceptions (e.g., oncology vs non-oncology Dx distinctions, ESRD exemptions). For device/implant procedures, advance notification may be required to start case management before scheduling.
Provider action summary: Always confirm member benefit coverage, obtain prior authorization when required before service, include diagnosis and clinical documentation to support medical necessity and site-of-service selection, and use the Provider Portal/chat/phone routes specified in the policy to avoid delays.