CurrentUnitedHealthcarePolicy N/A

Prior Authorization Requirements for New York Medicaid

Lists prior authorization requirements and submission methods for UnitedHealthcare Community Plan of New York participating providers for inpatient, outpatient, and other specified services.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-362-3368.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Online portalPrimary submission

866-362-3368Phone

>$500DME threshold

J9000-J9999Chemotherapy J-codes

Multiple servicesExplicit PA required

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.

Site-of-service rule

Services and Coverage Criteria Requiring Prior Authorization

Prior authorization required - illustrative list

Services requiring prior authorization as listed in this section include (examples):

Planned elective inpatient services require prior authorization (emergent/urgent care does not)

All non-emergent out-of-network services require prior authorization regardless of place of service

Bariatric surgery procedures (examples: 43644, 43645, 43659, 43770, 43775, 43842, 43845, 43846, 43847, 43848, 43860) require prior authorization

Bone growth stimulators (CPT 20975, 20979) require prior authorization

Cancer supportive care — colony-stimulating factor drugs and bone‑modifying agents administered in the outpatient setting for a cancer diagnosis require prior authorization

Cardiology outpatient and office-based diagnostic catheterizations, echocardiograms, electrophysiology implants, and stress echoes require prior authorization for participating physicians

Service-specific prior authorization criteria

Selected coverage and prior authorization requirements (by service/code):

Injectable chemotherapy drugs billed under J9000-J9999 and specified agents (e.g., J0640, J0641, J0642, J1950) require prior authorization; Q‑coded chemotherapy injectables and miscellaneous HCPCS-billed agents that lack assigned codes also require prior authorization

Continuous glucose monitors (A4238, A4239, E2102, E2103) require prior authorization

Cochlear implants and other auditory implants (e.g., CPT 69710, 69714, 69930; HCPCS L8614) require prior authorization

Cerebral seizure monitoring: prior authorization required for inpatient services (CPTs 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718); inpatient video EEG prior authorization not required for outpatient hospital or ambulatory settings

Durable medical equipment (listed codes) require prior authorization only when retail purchase or cumulative rental cost exceeds $500; prosthetics are not classified as DME

Prior authorization/notification requirements (excerpt)

Services and codes listed in these chunks require prior authorization or notification before performance or billing.

Functional endoscopic sinus surgery (FESS) CPT codes (e.g., 31240, 31253–31259, 31267, 31276, 31287, 31288) require prior authorization

Femoroacetabular impingement (FAI) procedures (CPT 29914–29916) require prior authorization

Genetic and BRCA-related testing (multiple CPT/Proprietary codes) require prior authorization/notification; ordering provider must notify the laboratory before DNA sequencing for BRCA testing

Items labeled experimental and/or investigational require prior authorization

Enteral nutrition services (B-codes such as B4102, B4103, B4104, B4150, B4152, B4153, B4158, B4159, B4160, B9002, B9998) are listed with prior authorization/notification context

Prior authorization and notification criteria (section excerpt)

Prior authorization/notification required as specified for the following categories and codes:

BRCA genetic testing (DNA sequencing): notification/prior authorization is required before sequencing; the ordering health care professional must notify the laboratory

Gender dysphoria-related surgeries: listed surgical CPT codes billed with F64.x diagnoses require prior authorization

Home health care (outpatient): prior authorization required only for outpatient settings and may include the member's home (examples: G0156, G0162, G0299, G0300, G0493–G0496)

Hysterectomy CPT codes listed (e.g., 58150, 58152, 58180, 58541–58573) require prior authorization

Injectable medications: numerous HCPCS/J-codes listed require prior authorization (see injectable medication section for code list)

Prior authorization requirement — injectable/specialty medications (codes listed)

This segment enumerates HCPCS/CPT codes for injectable and specialty medications and indicates they are subject to the payer's prior authorization process; some entries instruct to check the 'Medications newly approved by the' list.

Multiple injectable medications (HCPCS/J-codes listed throughout the document, e.g., J3262, J0800, J0172, J7171, J1931, J1426 and many others) require prior authorization

Selected specialty and high‑cost medications (examples in the list: Prolastin‑C J0256, Pegfilgrastim/filgrastim Q/J codes, J9202 Zolgensma referenced with J3399) require prior authorization and may be subject to Launch Medication List processes

For newly approved medications and unclassified codes, refer to the Medications newly approved/Launch Medication List guidance for submission and prior‑authorization expectations

Prior authorization criteria and submission instructions (partial)

Selected items and services require prior authorization as listed; submission methods and exceptions are noted.

Pre-determination is highly recommended for drugs on the Launch Medication List; submit prior authorization requests online via the Prior Authorization and Notification tool at UHCprovider.com or call 888-397-8129

Obtain prior notification for Cimzia via Magellan prior notifications services at 800-788-4005

Unclassified and temporary HCPCS codes (C9090, C9149, C9151, C9166, C9167, C9168, C9399, J3490, J3590) require prior authorization only for specified drugs (Nulibry T, Purified Cortrophin Gel, Rivfloza, Syfovre)

White blood cell colony-stimulating factors (codes J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require prior authorization for oncology and non-oncology diagnoses; oncology cases reference the cancer supportive care section; non-oncology submissions may be made online or by calling 877-842-3210

Orthotics and prosthetics: many L‑codes listed require prior authorization, and some items require prior authorization only when retail purchase exceeds specified dollar thresholds

Prior authorization criteria excerpt

Prior authorization requirements for specified services and codes

Outpatient therapy services (examples: CPT 97530, 92507, 97542, S9152) require prior authorization

Potentially unproven services (examples: CPT 33289, C2624) require prior authorization

Private duty nursing (T1000, T1002, T1003) requires prior authorization

Proton beam therapy (CPT 77520, 77522, 77523, 77525) requires prior authorization

Advanced outpatient imaging (selected CT/MRI/MRA/PET; examples: 0712T, 0698T, 0713T, 0710T, 0711T) requires prior authorization

Selected surgical procedures (shoulder surgery CPTs 29805–29828; sinuplasty CPTs 31295–31297) require prior authorization

Prior authorization criteria notes

Prior authorization requirements called out in this section:

Sleep studies: prior authorization required (note: prior authorization is not required for New York long‑term services and supports (LTSS) in specified contexts)

Spinal surgery procedures (multiple CPTs listed) require prior authorization

Implantation of stimulators and devices that send electrical impulses (including bone growth stimulators and neurostimulators; HCPCS examples E0747, E0748, E0749, E0760) require prior authorization

Prior authorization criteria and routing

Prior authorization requirements and routing instructions

Implantation of stimulators and bone growth stimulators requires prior authorization; specified HCPCS codes include E0747, E0748, E0749, E0760

Transplant and CAR T-cell therapy services require prior authorization and coordination with the UnitedHealthcare Community and State Transplant Case Management team (providers must call the team as directed in the document)

Ventricular assist devices (VAD) require prior authorization; providers should call the notification number on the member's ID card and then fax the form to the Optum VAD Case Management team at 855-282-8929

Vein procedures and wound vacs require prior authorization; multiple CPT/HCPCS codes are listed for these services

CPT/HCPCS/ICD-10 Code Lists and Coding Notes

Surgical CPT codes mapped to F64.x diagnosesCPT

14000	Adjunct procedures; facial reconstruction (mapped to F64.0)
14001	Adjunct procedures; facial reconstruction (mapped to F64.1)
14041	Adjunct procedures; other (mapped to F64.2)
15734	Muscle, myocutaneous or fasciocutaneous flap (mapped to F64.8)
15738	Pedicle graft (mapped to F64.0)
15750	Other flap (mapped to F64.1)
15757	Other flap (mapped to F64.2)
15758	Other flap (mapped to F64.8)
19303	Mastectomy for gender-affirming chest reconstruction (mapped to F64.0)
53410	Penile reconstructive procedure (mapped to F64.1)

1–10 of 23

1/3

Submission Methods, Routing, and Provider Responsibilities

Prior Authorization

General prior authorization submission and scope

Prior authorization is required for a broad set of services and items listed below. Submit requests online using the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal (UHCprovider.com -> Sign In -> Prior Authorization and Notification tab) or by phone using the numbers listed in the portal or on the member's ID card. Planned elective inpatient services always require prior authorization. Emergent/urgent care does not. All non‑emergent out‑of‑network services require prior authorization.

Online: UHCprovider.com -> Sign In -> Prior Authorization and Notification tab.
Phone: see portal or member ID card for the correct phone number for the service type.

Prior Authorization

Bariatric surgery prior authorization

Prior authorization is required for bariatric surgery. Providers must submit prior authorization requests through the Prior Authorization and Notification tool or the designated phone number. Ensure documentation includes BMI, prior weight‑loss attempts, comorbid conditions, and preoperative evaluation notes per UnitedHealthcare requirements.

Definitions and Thresholds

Planned elective inpatient service / emergent/urgent care

Planned elective inpatient servicesAll planned, elective inpatient service requests require prior authorization.

Emergent/urgent carePrior authorization is not required for emergent or urgent care (network or out-of-network).

Non-emergent out-of-network servicesAll non-emergent, out-of-network services require prior authorization regardless of place of service.

Cancer supportive care prior authorization scope

Scope — cancer supportive care drugsPrior authorization is required for colony-stimulating factor drugs and bone‑modifying agents administered outpatient for a cancer diagnosis.

Specific CSF codes

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Requirements for New York Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization requests via the Prior Authorization and Notification tool on the UnitedHealthcare Provider Portal or call 866-362-3368.

SourceLink

On This Page

Erectile dysfunction procedures and associated device/drug codes require prior authorization

Some DME/HCPCS items are subject to the cumulative rental/retail cost threshold (>$500) for prior authorization

Genetic/molecular testing codes: multiple CPT and proprietary codes are listed and require prior authorization/notification

Selected surgical procedures and services (joint replacement, non-emergent air transport, specified musculoskeletal CPTs) are indicated as requiring prior authorization per the Launch Medication List/Procedures section

Site-of-service rule: prior authorization is required when the service is requested in an outpatient hospital setting; prior authorization is not required if performed at a participating ambulatory surgery center (ASC)

Bariatric surgery requires prior authorization and completion of UnitedHealthcare clinical criteria.
Include objective weight/BMI history, conservative therapy attempts, and comorbidity documentation.

Prior Authorization

DME prior authorization threshold and listed codes

Durable medical equipment (DME) prior authorization is required only for the DME HCPCS codes listed when the retail purchase or cumulative rental cost exceeds $500. Providers should verify listed HCPCS codes and obtain authorization accordingly.

Prior authorization required for listed DME codes when retail purchase or cumulative rental cost > $500.
Examples of listed codes include A4575, A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, E0300, E0328, E0329, E0445, E0457, E0465, E0466, E0470, E0471, E0483, E0486, E0620, E0636, E0637.

Prior Authorization

V-code items requiring prior authorization

Certain HCPCS V‑codes require prior authorization. Verify the specific V‑code and obtain authorization prior to supplying the item or service.

V5270, V5271, V5272, V5274, V5281, V5282, V5283, V5286, V5287, V5288, V5290
Some V‑codes may have additional notes; always confirm via the portal.

Prior Authorization

Genetic and molecular testing (BRCA and others)

Genetic and molecular testing (including BRCA and many other molecular assays) require prior authorization/notification before testing is performed. The ordering provider must include the laboratory name and clinical rationale when requesting authorization.

BRCA testing CPT codes: 81162, 81163, 81164, 81228, 81229 — notification/prior authorization required before DNA sequencing.
Additional molecular/genetic CPT/PLA/U codes requiring authorization include 81400–81417, 81420, 81431–81440, 81445, 81448, 81460, 81465, 81479, 81507, 81518–81521, 81546, 81595, 81599, 87505–87507 and temporary/other codes 0006M, 0007M, 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0088U, 0111U, 0129U, 0026U.
Ordering provider must notify the laboratory and complete the authorization/notification process and indicate the performing laboratory in the request.

Prior Authorization

Misc genetic testing code

Miscellaneous genetic/testing codes and temporary/unclassified codes require prior authorization/notification. Confirm code-specific instructions and indicate the laboratory when submitting the request.

Temporary and unclassified codes: 0006M, 0007M, 0018U, 0022U, 0023U, 0026U, 0055U, 0060U, 0087U, 0088U, 0111U, 0129U.
Unclassified/other codes (examples): 81599, 81595, 87505–87507; notification/authorization required.

Prior Authorization

Gender dysphoria services

Gender dysphoria–related services, including medical and surgical treatments, require prior authorization. When submitting, include the diagnosis code (F64.0–F64.9 series) and the specific procedural codes. Coverage decisions are based on clinical documentation meeting UnitedHealthcare criteria.

Authorization required for gender dysphoria procedures; associated diagnosis codes include F64.0–F64.9 (with some mappings to Z87.890 as noted).
Examples of associated surgical CPT codes called out in the source include (but are not limited to) codes such as 19303, 19316, 19318, 19325 and a broad set of gender‑affirming procedure codes — verify the exact code for authorization and corresponding diagnosis.

Prior Authorization

Injectable medications and radiopharmaceuticals

Injectable medications and radiopharmaceuticals listed on the UnitedHealthcare Launch Medication List require prior authorization. Submit requests online via the Prior Authorization and Notification tool or call the phone number specified for medications. Some agents require special prior notification channels (see notes).

Examples of J‑codes requiring prior authorization include many specialty and biologic agents (e.g., J3262, J0800, J0172, J1931, J0597, J0567, J1786, J3247, J0584, J1551, J0589, J1413, J2508, J1302, J3380, J3111, J1305, J1428, J0177).
Therapeutic radiopharmaceuticals codes include A9513, A9590, A9606, A9607, A9699 and may require specific submission steps.
Unclassified and temporary codes (C9090, C9149, C9151, C9166, C9167, C9168, C9399, J3490, J3590) — prior authorization only required for specific drugs noted (e.g., Nulibry, Purified Cortrophin Gel, Rivfloza, Syfovre); follow Launch Medication List guidance.

Documentation Required

Zolgensma (gene therapy) coding notes

Zolgensma (onasemnogene abeparvovec) coding note: the applicable HCPCS/J‑code listed is J3399. Prior authorization/pre‑determination is required; follow the Launch Medication List and UnitedHealthcare medication submission process for gene therapies.

Zolgensma — J3399 (verify current code mapping at time of submission).
Pre‑determination is highly recommended for gene therapy agents; contact UnitedHealthcare Specialty/Medication review as instructed on the portal.

Note

Prior authorization codes (partial) and program notes

Prior authorization codes and program guidance are extensive and updated via the Launch Medication List. Providers should pre‑determine for drugs on that list and follow the specific submission channels noted (some require Magellan or other prior notification services).

Pre‑determination/pre‑authorization is highly recommended for listed medications.
Special instructions: Cimzia prior notification via Magellan (800‑788‑4005).
For oncology vs non‑oncology use of colony‑stimulating factors see cancer supportive care notes; certain J/Q codes require authorization for non‑oncology diagnoses as well.

Documentation Required

Prior authorization and notification instructions

Prior authorization and notification instructions: use the UnitedHealthcare Provider Portal Prior Authorization and Notification tool for most requests. Phone numbers and alternate submission instructions are provided on the portal and in section‑specific callouts. For therapeutic radiopharmaceuticals and many oncology‑related drugs, a separate phone line is provided in the portal.

Online submission is the preferred method: UHCprovider.com -> Prior Authorization and Notification tab.
If phone submission is needed, use the service‑specific phone numbers listed in the portal or the Launch Medication List.
Include clinical documentation, diagnosis, prior conservative care, and performing laboratory or supplier when applicable.

Prior Authorization

Procedures requiring prior authorization (selected)

Selected procedures require prior authorization. This includes (but is not limited to) advanced outpatient imaging, joint replacement, various ENT and sinus surgeries, spinal surgeries, hysterectomy, shoulder and other orthopedic surgeries, FAI procedures, FESS, cochlear implants, continuous glucose monitors, and many others listed in the provider procedures list. Always confirm the specific CPT/HCPCS code and obtain authorization before scheduling.

Examples of selected procedures requiring authorization: joint replacement (various CPTs listed in Launch Medication List), FESS (31240, 31253–31259, 31267, 31276, 31287–31288), spinal surgery series (22100–22224, 22510, 22206–22214, etc.), hysterectomy (58150, 58152, 58180, 58260–58292, 58541–58554), shoulder surgery codes (29805–29807, 29819–29828), sinuplasty (31295–31297).
Site‑of‑service rule: prior authorization is required only when requesting outpatient hospital setting for certain procedures; not required when performed at a participating ASC.

Prior Authorization

Orthotics & prosthetics prior authorization requirements

Orthotics and prosthetics: prior authorization is required for many L‑series codes and prosthetic items listed. Authorization is required when the retail purchase exceeds the DME threshold or as otherwise noted. Providers must supply the item code, clinical justification, and cost information when requesting authorization.

Examples of orthotics/prosthetics codes included: L0112, L0170, L0456, L0462, L0464, L0480, L0482, L0484, L0486, L0624, L0629, L0631, L0632, L0634, L0636, L0637, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1499, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1820, L1832, L1834, L1840, L1844, L1845, L1846, L1860, L1945, L1950, L1970, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2060, L2106, L2108, L2126, L2136, L2350, L2510, L2526, L2627, L2628, L3230, L3265, L3649, L3671, L3674, L3720, L3730, L3740, L3763, L3764, L3900, L3901, L3904, L3905, L3961, L3971, L3975, L3976, L3977, L3999, L4000, L4010, L4020, L4631, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5420, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5613, L5614, L5616, L5639, L5640, L5642, L5643, L5644, L5646, L5647, L5648, L5649, L5651, L5653.
Prosthetics are not considered DME for some rules; follow specific guidance in the portal.

Prior Authorization

Outpatient therapy prior authorization

Outpatient therapy services (physical, occupational, speech) require prior authorization for certain CPT codes. Verify the specific code and clinical indication when submitting a request.

Examples of outpatient therapy CPTs referenced: 97530, 92507, 97542, S9152.
Include therapeutic plan, frequency, and functional goals with authorization request.

Prior Authorization

Private duty nursing prior authorization

Private duty nursing services require prior authorization. Submit documentation that outlines the skilled nursing needs, hours requested, and supporting clinical notes.

Private duty nursing HCPCS/T codes include T1000, T1002, T1003.
Authorization must document skilled nursing needs and rationale for private duty level of care.

Prior Authorization

Proton beam therapy prior authorization

Proton beam therapy requires prior authorization. Use the Prior Authorization and Notification tool and include relevant radiation oncology records and justification.

Proton therapy CPTs: 77520, 77522, 77523, 77525.
Provide clinical rationale, tumor details, and prior radiation history when requesting authorization.

Prior Authorization

Advanced outpatient imaging prior authorization

Advanced outpatient imaging (certain CT, MRI, MRA, PET) requires prior authorization. Submit imaging requests with clinical indication, prior imaging results, and relevant history to the portal.

Advanced imaging may include category III / temporary CPTs and other specific codes (e.g., 0698T, 0710T–0713T, and others listed in the portal).
Authorization is required for participating physicians requesting these advanced outpatient procedures.

Prior Authorization

Prior authorization notes for sleep studies and spinal surgery

Sleep studies and spinal surgery require prior authorization. For sleep studies, applicable CPTs include 95805–95811, 95807–95810 as listed; for spinal surgery, many CPTs in the 22100–22224, 22510 series require authorization. Include prior conservative management and diagnostic testing in requests.

Sleep study CPTs: 95805, 95811, 95807, 95808, 95810 (per indication).
Spinal surgery examples: 22100–22112, 22114, 22206–22214, 22220, 22224, 22510, etc.
Prior authorization is required for these services (exceptions apply for certain LTSS programs — verify member plan).

Prior Authorization

Prior authorization for stimulator/device implantation

Implantation of stimulators or other implanted devices (including bone growth stimulators, spinal stimulators, and other electrical‑impulse devices) requires prior authorization. Provide device type, indication, prior conservative care, and relevant diagnostic testing.

Bone growth stimulators and related E‑codes (E0747, E0748, E0749) require prior authorization.
Include fracture healing history or other objective indications when requesting authorization for stimulation devices.

Prior Authorization

Transplants and CAR-T cell therapy

Transplants and CAR‑T cell therapy services require prior authorization and coordination with the UnitedHealthcare Community and State Transplant Case Management team. Call the transplant case management team as instructed on the portal and follow the specialized authorization workflow for transplant and cellular therapies.

Prior authorization required for transplants and CAR‑T therapies (examples: Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta, Zynteglo).
Providers must contact the UnitedHealthcare Community and State Transplant Case Management team for authorization and case coordination.
Many related CPT/HCPCS and unclassified codes (e.g., 0537T–0540T, J9999, Q2041–Q2056, CAR‑T related codes) are subject to the transplant/CAR‑T authorization process.

Codes requiring prior authorization include J1442, J1447, J2506, Q5101, Q5108, Q5110, Q5111, Q5120 and Q5122 (also require PA for non‑oncology DX).

Submission for oncology vs non‑oncologyFor oncology DX see the cancer supportive care section; non‑oncology CSF submissions use UHCprovider.com or call 877‑842‑3210 per Launch Medication List guidance.

DME prior authorization threshold

DME prior authorization threshold ruleDurable medical equipment listed requires prior authorization only if retail purchase or cumulative rental cost is over $500.

Affected codesIncludes many HCPCS codes listed in the DME section (e.g., A4575, A9279, E0265, E0266, E0270, E0329, etc.).

Prosthetics clarificationProsthetics are noted as not DME and are treated separately in the Launch Medication List/orthotics & prosthetics section.

Chemotherapy injectable prior authorization

Chemotherapy injectable prior authorizationInjectable chemotherapy drugs billed under J9000–J9999 (and select agents such as J0640, J0641, J0642, J1950) require prior authorization.

Q‑coded and miscellaneous HCPCSChemotherapy injectables with a Q‑code or those billed under miscellaneous HCPCS (unassigned codes) also require prior authorization.

Submission methodSubmit prior authorization requests online using the Prior Authorization and Notification tool (UHCprovider.com).

prosthetics

Prosthetics definitionProsthetics are distinguished from DME; many orthotics/prosthetics L‑codes are listed in the Launch Medication List and may require prior authorization.

L‑code examplesLaunch Medication List maps numerous L‑codes (e.g., L0112, L0464, L0480, L0624, etc.) and indicates PA requirements or purchase threshold rules.

Retail/cost rule referenceSome prosthetic/orthotic items require PA when retail purchase exceeds specified thresholds (see Launch Medication List mapping).

BRCA testing notification/prior authorization

BRCA testing notification requirementNotification/prior authorization is required before DNA sequencing for BRCA testing; the ordering health care professional must notify the laboratory.

Relevant CPT/proprietary codesBRCA‑related codes cited include 0087U, 0088U, 0111U, 0129U and others listed in the genetic testing section.

Procedure contextBRCA notification language appears alongside other genetic/molecular testing prior authorization/notification requirements.

BRCA testing notification/prior authorization

Ordering provider responsibility for BRCAThe ordering health care professional must notify the laboratory prior to performing DNA sequencing for BRCA tests.

Notification repeatsThe policy repeats that notification/prior authorization is required before DNA sequencing for BRCA testing (see genetic testing entries).

Associated codesEntries reference S3870 and multiple CPT/HCPCS genetic testing codes in the same context.

Home health (outpatient) prior authorization

Home health (outpatient) PA scopeHome health care prior authorization is required only in outpatient settings and may include visits to the member's home.

Relevant HCPCS/G codesHome health related codes referenced include G0156, G0162, G0299, G0300 and others in the home health section.

Setting limitationThis PA requirement applies to outpatient/home settings; inpatient home health or LTSS exceptions may differ per notes elsewhere.

Therapeutic radiopharmaceuticals

Therapeutic radiopharmaceuticalsTherapeutic radiopharmaceuticals are listed (A9‑series examples such as A9513, A9590, A9606, A9607, A9699) and are subject to prior authorization per the injectable medications section.

Submission instructionFor radiopharmaceuticals, submit prior authorization requests online via the Prior Authorization and Notification tool or call the phone number provided (888‑397‑8129).

Code groupingA9‑series HCPCS codes are identified specifically under the therapeutic radiopharmaceuticals heading.

Unclassified/temporary codes

Unclassified/temporary codes usageUnclassified and temporary codes (C9‑series and miscellaneous J3490/J3590/J3399 entries) are used for newer or unclassified injectable products and appear in the injectable medications section.

PA requirement exceptionsLaunch Medication List notes that prior authorization for some unclassified/temporary codes is required only for specific drugs (e.g., Nulibry T, Purified Cortrophin Gel, Rivfloza, Syfovre).

Guidance to check launchesPolicy repeatedly directs providers to 'Please check our Medications newly approved by the' (Review at Launch) for up‑to‑date PA guidance on such codes.

J3399

J3399 referenceHCPCS code J3399 is repeatedly referenced in the document in association with unclassified drug entries and new launches; providers are directed to check Launch/Review guidance.

Association with new medicationsJ3399 appears alongside messaging to consult the 'Medications newly approved by the' list for current authorization requirements (see Launch Medication List guidance).

Use in Zolgensma entriesJ3399 is used in the same sections that reference Zolgensma, indicating J3399 may be used as an unclassified drug code in this context.

Zolgensma

Zolgensma mentionZolgensma is repeatedly mentioned with HCPCS code J9202 and referenced alongside J3399; the document directs providers to check Launch/Medications guidance for up‑to‑date PA instructions.

Coding notesEntries reference both J9202 and J3399 in Zolgensma context, and instruct providers to consult the 'Medications newly approved by the' list for authorization details.

Actionable stepVerify Zolgensma prior authorization requirements via the Launch Medication List and the Prior Authorization and Notification tool before billing.

Review at Launch for New to Market

Review at Launch (New to Market)'Review at Launch for New to Market' guidance applies — pre‑determination is highly recommended for drugs on the Launch Medication List.

Launch Medication List instructionThe document directs providers to consult the Launch Medication List and related policies for the most up‑to‑date PA requirements for newly approved medications.

Pre‑determination recommendedPre‑determination is explicitly recommended for drugs on the Launch Medication List; follow portal or phone submission guidance provided.

Pre-determination / prior notification

Pre‑determination / prior notification methodsSubmit prior authorization requests online via the Prior Authorization and Notification tool at UHCprovider.com or call the listed phone number(s) (e.g., 866‑362‑3368; Launch list phone numbers such as 888‑397‑8129 or 877‑842‑3210 for specific items).

Cimzia prior notificationObtain prior notification for Cimzia through Magellan prior notifications at 800‑788‑4005 as noted on the Launch Medication List.

Launch list exceptionsSome Launch Medication List entries require prior notification rather than full PA; follow the specific instructions in the Launch Medication List entry.

Proton beam therapy

Proton beam therapy definitionProton beam therapy: Focused radiation therapy using beams of protons (tiny positively charged particles).

PA requirementPrior authorization is required for proton beam therapy and the listed CPT codes (77520, 77522, 77523, 77525).

Submission instructionSubmit prior authorization requests online via the Prior Authorization and Notification tool or by phone as specified for radiology/oncology items.

Site of service (SOS) - Outpatient hospital

SOS — Outpatient hospital rulePrior authorization is required when requesting service in an outpatient hospital setting.

ASC exceptionPrior authorization is not required if the same service is performed at a participating ambulatory surgery center (ASC).

Examples referencedMultiple CPT examples (e.g., 58561, 58562 under outpatient hospital SOS) appear in the SOS section to illustrate the rule.

Site of service (SOS)

Site of service (SOS) conceptSite of service (SOS) determines PA requirement — outpatient hospital requests require prior authorization; performing at participating ASC may obviate PA.

Code mapping examplesThe SOS sections include numerous CPT examples and mappings showing which procedures appear under outpatient hospital SOS; consult those entries for code‑level guidance.

Provider actionWhen scheduling, verify place of service; if outpatient hospital is requested, submit prior authorization per policy guidance.

Ventricular assist devices (VAD)

Ventricular assist devices (VAD) definitionVentricular assist devices (VAD) are mechanical pumps that take over the function of a damaged ventricle and restore normal blood flow.

Prior authorization and routingPrior authorization is required for VADs; providers must call the notification number on the member's ID card and then fax the required form to Optum VAD Case Management at 855‑282‑8929.

Use of unclassified codesVAD entries reference unclassified HCPCS/J‑codes (e.g., C9399, J3490, J3590) in prior authorization instructions.

Vein procedures / saphenous vein ablation

Vein procedures / saphenous vein ablation requirementVein procedures (removal/ablation of saphenous veins and related branches) require prior authorization.

Codes and unclassified entriesProcedures reference CPT codes such as 36473, 36475, 36478, 37700, 37718, 37722, 37765, 37766 and unclassified HCPCS (C9399, J3490, J3590) in the vein procedures section.

VAD/wound vac groupingVein procedures are listed alongside VADs and wound vacs in the document as services requiring prior authorization; follow specific code entries for PA submission details.